HospitalInspections.org

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

Based on observations on the behavioral health unit, facility documentation and clinical record review, the facility failed to provide care in a safe setting on the psychiatric unit when it was identified that sleeping rooms and units were not maintained in such a manner to promote the safety and well-being of patients.

Please see A144

Based on observations on the behavioral health unit, facility documentation and clinical record review, the facility failed to provide care in a safe setting on the psychiatric unit when it was identified that sleeping rooms and units were not maintained in such a manner to promote the safety and well-being of patients. The findings include:

Observations during a tour of the psychiatric unit on 10/16/18 at 1:40PM identified multiple ligature points that included the following:
a. 18 patient beds were not designed to a psychiatric/institutional standard and had identified ligature points, i.e.: metal frames, wooden head and footboards and plastic head and foot boards with holes in them
b. patient bed room doors were noted with exposed door hinges
c. bedroom doors were identified with 3 different types of door knobs/handles that were ligature points
d. "no-entry" tubular metal swing gates between the nurse's station and common hallways had large openings


Interview with the Compliance Officer on 10/16/18 at 2:15PM stated that the facility had conducted a risk assessment (updated on 9/28/18) prior to the survey. An action plan to remove the ligature risks was developed and the facility was in the process of completing components of the plan.

Interview with the Unit Manager on 10/16/18 at 2:10PM stated that environmental rounds are conducted every shift and that all patients are monitored at least every 15 minutes.
Review of the psychiatric unit environmental rounds documentation failed to include observations of the door hinges, non-psychiatric designed beds, curtains or door knobs.

The unit census on 10/16/18 was 17. There were no patient's with current suicidal ideation or self-harm tendencies.

Subsequent to surveyor inquiry an action plan was submitted that indicated the following:
a. Implementation of education to all staff on ligature risks in the environment, addition of environmental rounding every 15 minutes, patient suicidal risk assessments on admission and every shift while awake, and provision of 1 to 1 or constant observation as deemed necessary.

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

Based on observations on the behavioral health unit, facility documentation and clinical record review, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner to promote the safety and well-being of patients.

Please see A701

Based on observations on the behavioral health unit, facility documentation and clinical record review, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner to promote the safety and well-being of patients. The findings include:

Observations during a tour of the psychiatric unit on 10/16/18 at 1:40PM identified multiple ligature points that included the following:

a. 18 patient beds were not designed to a psychiatric/institutional standard and had identified ligature points, i.e.: metal frames, wooden head and footboards and plastic head and foot boards with holes in them
b. patient bed room doors were noted with exposed door hinges
c. bedroom doors were identified with 3 different types of door knobs/handles that were ligature points
d. "no-entry" tubular metal swing gates between the nurse's station and common hallways had large openings


Interview with the Compliance Officer on 10/16/18 at 2:15PM stated that the facility had conducted a risk assessment (updated on 9/28/18) prior to the survey. An action plan to remove the ligature risks was developed and the facility was in the process of completing components of the plan.

Interview with the Unit Manager on 10/16/18 at 2:10PM stated that environmental rounds are conducted every shift and that all patients are monitored at least every 15 minutes.
Review of the psychiatric unit environmental rounds documentation failed to include observations of the door hinges, non-psychiatric designed beds, curtains or door knobs.

The unit census on 10/16/18 was 17. There were no patient's with current suicidal ideation or self-harm tendencies.

Subsequent to surveyor inquiry an action plan was submitted that indicated the following:

a. Implementation of education to all staff on ligature risks in the environment, addition of environmental rounding every 15 minutes, patient suicidal risk assessments on admission and every shift while awake, and provision of 1 to 1 or constant observation as deemed necessary.