HospitalInspections.org

The Condition of Physical Environment has not been met. Based on clinical record review, review of hospital environment of care documents, observations and interviews with staff, the hospital failed to ensure that the behavioral health in-patient units were free from points of ligature and/or that an effective safety plan was in effect to ensure the safety of the psychiatric patient while the environmental hazards existed.


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Based on clinical record review, review of hospital environment of care documents, observations and interviews with staff, the hospital failed to ensure that the behavioral health in-patient units were free from points of ligature and/or that an effective safety plan was in effect to ensure the safety of the psychiatric patient while the environmental hazards existed. The findings include:


1. On 11/27/17 at 9:40 AM, the surveyor, while accompanied by the Director of Operations, observed the following conditions:

a. Observations made on the ninth (9th) floor Behavioral Health Unit identified that a water supply pipe mounted on the rear of the toilets within all of the patient rooms throughout the entire BHU created an area that could be used as a ligature point. Subsequent to this observation the bathrooms were locked and staff relocated at risk patients to another facility until the water supply pipe issue was repaired.

b. The patient bathrooms within the ninth (9th) floor Behavioral Health Unit (BHU) were provided with non- institutional style, tamper resistant screws/fasteners in fixtures, hardware, and construction components that posed a potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides.

Review of the hospital's environment of care ligature risk assessment dated 10/31/17 identified that existing toilets on the physchiatric unit were assessed as a being a point of ligature due to exposed pipes and were to be covered. However, observations on 11/27/17 identified that the pipes had not been covered, as identified in the risk assessment. In addition, the assessment identified that not all screws used on the psychiatric unit were tamper resistant and were to be replaced. However, observations on 11/27/17 identified that the screws had not been replaced.

A tour of the patient care unit and clinical record review on 11/27/17 identified a census of 8 patients. Five of the 8 patients were assessed and identified as not suicidal. These 5 patients were subsequently transferred to the hospital's off-site psychiatric unit for continued care. 3 patients remained on the unit, assessed for suicidality and were placed on one-to-one supervision while the ligature risks remained in the environment.





2. On 11/29/17 at 9:15 AM a tour of the psychiatric units at the Westport campus identified that 3 patient care units had lounges with wood-framed couches and chairs with wood slats beneath the cushions that posed a ligature risk when the lounges were not in direct line of sight by staff. Review of the hospital's environment of care ligature risk assessment for the Westport campus dated 10/31/17 failed to identify the wood-framed couches and chairs as potential risks.

The lounges were locked between 10:00 PM to 7:00 AM. Resident's were allowed to be in the lounges independently between 7:00 AM and 10:00 PM.

Review of the hospital's environment of care ligature risk assessment dated 10/31/17 identified that furniture on the physchiatric unit should be free of anchor points to prevent hanging.

Interview with the Senior Director of Administrative Services on 11/29/17 at 12:45 PM identified that the lounge furniture had not been identified as a safety risk. Subsequent to surveyor inquiry, the lounge furniture was removed.

Review of clinical records identified that only 1 in-patient (Patient #32) was suicidal and had been on one-to-one supervision prior to the 11/29/17 inspection.