HospitalInspections.org

16281

Based on observation and interview, the facility failed to maintain the physical plant and hospital environment in a manner that the safety and well-being of patients were assured.

Findings:

According the Statement of Deficiencies and Plan of Correction dated 4/ 9/10, the facility received a deficiency for having an exposed sink drain pipe and a standard type sink faucet fixture to which a noose would not slip off with the weight of a person in the bathroom of the Las Encinas School, and also for having an accessible receptacle in the same bathroom. At the time of the full recertification survey completed on 4/9/10, the on campus school was attended by patients from Mariah East acute psychiatric unit.

The facility's plan of correction in response to the 4/9/10 full recertifcation survey indicated "The Mariah East and Las Encinas School Unit(s) has been closed for extensive renovation" with a completion date of 4/19/10, and another plan of correction indicated "Suicide-safe sink faucets have been replaced/installed" with a completion date of 4/26/10.

On 1/25/11 between 8:00 a.m. and 9:25 a.m., during a follow-up survey, the Chief Operating Officer (COO) stated that the Las Encinas School was closed and no changes had occurred at the school since the last survey (4/9/10) by the evaluator. The COO stated that there were no changes had occurred at the school because there were no longer any minors that would go to the school, that at no time are patients in the school and that the school would be torn down to construct a new building.

The COO also stated there was no documentation about the school remaining closed and not being open again for patient occupancy.

On 1/27/11 at 10:15 a.m., accompanied by the COO and the Plant Operations Supervisor, the evaluator observed that although the school was closed during the follow-up survey, there was still an exposed sink drain pipe and a standard type sink faucet fixture to which a noose would not slip off with the weight of a person in the bathroom of the school. Closer observation revealed there was also still an accessible receptacle in the same bathroom.

By the end of the follow-up survey, the facility did not provide any documentation ensuring the Las Encinas School would remain closed and that patients would not occupy the school.

This was a repeat deficiency from the survey completed on 4/19/10.