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Based on a tour of the hospital, a review of hospital documentation and staff interviews, the hospital's quality assurance and performance improvement (QAPI) program failed to identify ligature points on multiple psychiatric units to ensure safe quality care.

Please refer to A 0273 , A0308

Based on a tour of the hospital, a review of hospital documentation and staff interviews the hospitals quality assurance improvement program failed to conduct a comprehensive assessment of the environment, collect data, measure and track the provision of risks related to ligature points on multiple psychiatric units to ensure the well-being of patients. The finding included:

Observation during tour with the Director of Nursing, the Executive Director of Nursing and the Nurse Manager of the Mount Sinai campus on 10/20/17 identified multiple ligature points throughout the psychiatric units which included a child unit, adolescent units, and adult units. Observation identified the following:

a. Carts with monitors and game equipment located in the child/adolescent units had long electrical cords. Subsequent to the surveyors inquiry on 10/20/17, the carts with game equipment was removed and secured to a locked area.

b. A television unit had long electrical cords located in the child/adolescent units. Subsequent to the surveyors inquiry on 10/20/17, the television was removed and secured to a locked area.

c. The creative therapy and groups rooms for all psychiatric units had scissors, cleaning supplies, an iron and paints in the cabinets that were not locked. Further review identified that patients are escorted by staff to the room and staff are always in attendance when patients are in the creative therapy/group rooms. The Nurse Manager further indicated that keys were not available to lock the cabinets.

d. The group rooms and creative therapy rooms on the adolescent/child units had handles on the cabinets that were potential ligature points. Subsequent to the surveyors inquiry on 10/20/17 at PM, the Director of Nursing indicated groups would be held in a common area until the risk could be mitigated.

e. It was observed on 10/20/17 at 4:45pm that patients go off the all psychiatric units to a therapy room and use the bathroom located outside the therapy room. Further review identified that patients are escorted to the bathroom, however, the patients are in the bathroom facilities alone. The bathroom plumbing was exposed and not covered, which posed a ligature risk.

f. A metal elbow on a door within the unit located on both 7 West and 8 West was protruding by approximately twelve inches in area that was not in constant observation by staff.

Interview and review of the environmental rounds sheets with Nurse Manager #4 and #5 on 10/30/17 at 1:00 PM dated 1/26/17 through 9/28/17 failed to identify the assessment of ligature points on all psychiatric units. Nurse Manager #4 and #5 indicated environmental assessments were conducted twice a year by a team of employees that included both clinical and facility staff members however, ligature points were not included in the risk assessment and should have been.

An alternate accreditation agency conducted an assessment of the environment in September of 2017. Interview and review of agencies findings with the Manager of Engineering on 10/31/17 at 11:30 AM indicated twenty seven areas had been identified as a ligature/safety risk on multiple psychiatric units. The Manager of Engineering identified that although some of the environmental risks were identified by the alternate accreditation body had been corrected, others had not been completed as of 10/31/17.

Further interview with the Manager of Engineering identified on 10/8/17 the hospital utilized an outside consultant that conducted a comprehensive environmental assessment of all psychiatric units. Interview and review of consultants findings with the Manager of Engineering on 10/31/17 at 12:00 PM indicated fifty eight areas in total had been identified as a ligature/safety risk on the psychiatric units. The Manager of Engineering indicated although some of the environmental risks that were identified by the consultant had been corrected, others had not been completed as of 10/31/17.

Interview and review of the unit quality committee minutes dated 1/6/17 through 9/14/17 with Nurse Manager #4 and
#5 on 10/30/17 at 1:00 PM identified the unit quality committee met quarterly, however, failed to identified ligature risk as part of their quality program. Further interview with Nurse Manager #4 and #5 indicated ligature risk should have been included as a quality indicator to ensure the safety and well-being of the patients and had not been conducted.

Interview and review of the hospital wide quality assurance program with the Director of Quality on 10/31/17 at 2:00 PM identified the psychiatric units reported to the quality assurance program annually, however, failed to report ligature risk as part of the environmental assessment, tracking and/or monitoring for safety and quality. Further interview with the Director of Quality indicated a ligature risk assessment, data collection, tracking and monitoring would be incorporated into both the unit based and hospital wide QAPI program.

Review of the Quality Committee responsibilities in part directed that the quality committee would provide organizational-wide oversight to the quality and safety of care delivered throughout the organization. The purpose of the committee was to promote high reliable, safe, high quality care and experience to each patient. The committee would be responsible to ensure specific performance improvement projects that were aligned with the organizations's strategic goals, safety and quality metrics. The committee would ensure prioritization and organizational performance improvement initiatives through the use of data, address barriers to progress, review, analyze and respond to patient safety issues. Moreover, the committee would review, update, and recommend approval of the organizational annual performance improvement plan and communicate system performance improvement priorities and initiatives.

Based on a tour of the hospital, a review of hospital documentation and staff interviews the hospitals governing body failed to ensure that the quality assurance improvement program reflected the complexity of multiple psychiatric units related ligature risk to ensure the well-being of patients. The finding included:

Observation during tour with the Director of Nursing, the Executive Director of Nursing and the Nurse Manager of the Mount Sinai campus on 10/20/17 identified multiple ligature points throughout the psychiatric units which included a child unit, adolescent units, and adult units. Observation identified the following:

a. Carts with monitors and game equipment located in the child/adolescent units had long electrical cords. Subsequent to the surveyors inquiry on 10/20/17, the carts with game equipment was removed and secured to a locked area.

b. A television unit had long electrical cords located in the child/adolescent units. Subsequent to the surveyors inquiry on 10/20/17, the television was removed and secured to a locked area.

c. The creative therapy and groups rooms for all psychiatric units had scissors, cleaning supplies, an iron and paints in the cabinets that were not locked. Further review identified that patients are escorted by staff to the room and staff are always in attendance when patients are in the creative therapy/group rooms. The Nurse Manager further indicated that keys were not available to lock the cabinets.

d. The group rooms and creative therapy rooms on the adolescent/child units had handles on the cabinets that were potential ligature points. Subsequent to the surveyors inquiry on 10/20/17 at PM, the Director of Nursing indicated groups would be held in a common area until the risk could be mitigated.

e. It was observed on 10/20/17 at 4:45pm that patients go off the all psychiatric units to a therapy room and use the bathroom located outside the therapy room. Further review identified that patients are escorted to the bathroom, however, the patients are in the bathroom facilities alone. The bathroom plumbing was exposed and not covered, which posed a ligature risk.

f. A metal elbow on a door within the unit located on both 7 West and 8 West was protruding by approximately twelve inches in area that was not in constant observation by staff.

Interview and review of the environmental rounds sheets with Nurse Manager #4 and #5 on 10/30/17 at 1:00 PM dated 1/26/17 through 9/28/17 failed to identify the assessment of ligature points on all psychiatric units. Nurse Manager #4 and #5 indicated environmental assessments were conducted twice a year by a team of employees that included both clinical and facility staff members however, ligature points were not included in the risk assessment and should have been.

An alternate accreditation agency conducted an assessment of the environment in September of 2017. Interview and review of agencies findings with the Manager of Engineering on 10/31/17 at 11:30 AM indicated twenty seven areas had been identfied as a ligature/safety risk on multiple psychiatric units. The Manager of Engineering identified that although some of the environmental risks that were identified by the alternate accreditation body had been corrected, others had not been completed as of 10/31/17.

Further interview with the Manager of Engineering identified on 10/8/17 the hospital utilized an outside consultant that conducted a comprehensive environmental assessment of the psychiatric units. Interview and review of consultants findings with the Manager of Engineering on 10/31/17 at 12:00 PM indicated fifty eight areas in total had been identfied as a ligature/safety risk on the psychiatric units. The Manager of Engineering indicated although some of the environmental risks that were identified by the consultant had been corrected, others had not been completed as of 10/31/17.

Interview and review of the unit quality committee minutes dated 1/6/17 through 9/14/17 with Nurse Manager #4 and #5 on 10/30/17 at 1:00 PM identified the unit quality committee met quarterly, however, failed to identified ligature risk as part of their program. Further interview with Nurse Manager #4 and #5 indicated ligature risk should have been included as a quality indicator to ensure the safety and well-being of the patients and had not been.

Interview and review of the hospital wide quality assurance program with the Director of Quality on 10/31/17 at 2:00 PM identified the psychiatric units reported to the quality assurance program annually, however, failed to report ligature risk as part of the environmental assessment, tracking and/or monitoring for safety and quality. Further interview with the Director of Quality indicated a ligature risk assessment, data collection, tracking and monitoring would be incorporated into both the unit based and hospital wide QAPI program.

Review of the Quality Committee responsibilities in part identified that the quality committee provided organizational-wide oversight to the quality and safety of care delivered throughout the organization. The purpose of the community was to promote high reliable, safe, high quality care and experience to each patient. The committee would be responsible to ensure specific performance improvement projects that were aligned with the organizations's strategic goals, safety and quality metrics. The committee would ensure prioritization and organizational performance improvement initiatives through the use of data, address barriers to progress, review, analyze and respond to patient safety issues. Moreover, the committee would review, update, and recommend approval of the organizational annual performance improvement plan and communicate system performance improvement priorities and initiatives.

Further interview with the Director of Quality on 10/31/17 at 2:15 PM identified the hospital wide quality assurance and improvement committee failed to report ligature risk related to the multiple psychiatric units to the hospital's governing body as the quality committee was not aware that the environmental risk assessment did not include an a review of ligature points.

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

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that multiple psychiatric units were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.


Please see A701

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that multiple psychiatric units were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy. The findings include:

Observation during tour with the Director of Nursing, the Executive Director of Nursing and the Nurse Manager of the Mount Sinai campus on 10/20/17 identified multiple ligature points throughout the psychiatric units which included a child unit, adolescent units, and adult units. Observation identified the following:

a. Carts with monitors and game equipment located in the child/adolescent units had long electrical cords. Subsequent to the surveyors inquiry on 10/20/17, the carts with game equipment was removed and secured to a locked area.

b. A television unit had long electrical cords located in the child/adolescent units. Subsequent to the surveyors inquiry on 10/20/17, the television was removed and secured to a locked area.

c. The creative therapy and groups rooms for all psychiatric units had scissors, cleaning supplies, an iron and paints in the cabinets that were not locked. Further review identified that patients are escorted by staff to the room and staff are always in attendance when patients are in the creative therapy/group rooms. The Nurse Manager further indicated that keys were not available to lock the cabinets.

d. The group rooms and creative therapy rooms on the adolescent/child units had handles on the cabinets that were potential ligature points. Subsequent to the surveyors inquiry on 10/20/17 at 5pm, the Director of Nursing indicated groups would be held in a common area until the risk could be mitigated.

e. It was observed on 10/20/17 at 4:45pm that patients go off the all psychiatric units to a therapy room and use the bathroom located outside the therapy room. Further review identified that patients are escorted to the bathroom, however, the patients are in the bathroom facilities alone. The bathroom plumbing was exposed and not covered, which posed a ligature risk.

f. A metal elbow on a door within the unit located on both 7 West and 8 West was protruding by approximately twelve inches in area that was not in constant observation by staff.

Interviews with the Director of Nursing, the Executive Director of Nursing and the Nurse Manager on 10/20/17 at 5:15pm indicated although routine environmental rounds had been conducted by the hospital, it was identified that an alternate accreditation agency conducted an assessment of the environment in September of 2017 and identified the hospital's environmental assessment was not comprehensive and the assessment identified multiple ligature risks. Subsequently, the hospital utilized a consultant who conducted a full environmental assessment on 10/8/17. Further interview with the Director of Nursing indicated that some of the environmental risks had been completed and a plan was in place to complete the rest.

Review of the 2016 psychiatric risk assessment conducted by the hospital identified cords over three feet in length on the child/adolescent units, however observation of the cords identified that they were still present on 10/20/17.

The Department requested and received an immediate plan of correction dated 10/20/17 which identified that television carts, game equipment, and televisions that contained long electric cords would be immediately removed. The creative therapy and group room would not be used and groups would be provided in the common area. A staff member would be stationed to visualize the area where the elbow attachments were found on the doors until they could be removed. The nursing supervisor would be responsible to ensure compliance with the immediate plan of correction.




2. Based on tour and observations of the Emergency Department (ED) psychiatric treatment area, the hospital failed to ensure a safe environment when 4 of 7 sinks had paddle-type hot and cold water levers that posed a potential ligature point. The findings include:

A tour of the ED psychiatric treatment area with the Director of the ED on 10/30/17 at 2:00 PM identified 4 sinks in the common hallway that were accessible to patients. Each sink had paddle-type hot and cold water levers that posed a potential ligature point. Although the sinks were in a common hallway with staff in the vacinity, the sinks were not being monitored by staff as a potential ligature point.