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Based on observation and interview, the hospital failure to ensure the physical environment was maintained in a manner to ensure an acceptable level of safety and quality for patients requiring acute inpatient psychiatric care, who had been admitted for being a danger to self or others. This deficient practice was evidenced by the toilet seats in the patients' bathrooms could be raised providing additional access for potential ligature anchors.

Findings:
An observation was conducted on 4/11/2022 between 10:00 a.m. and 11:00 a.m. of the patients' bathrooms on Unit 300 and the Unit 200. The following patient bathrooms had toilet seats that could be raised providing additional access for potential ligature anchors; rooms 303, 304, 306, 307, 308 and room 207.

An interview was conducted with S4FM on 04/12/2022 at 10:00 a.m. He reported the toilet seats are glued down with silicon, but the male patients pull on the toilet seats to raise the seat and the silicon loosens and the seat becomes unglued. S4FM confirmed the toilets seats are a ligature risk once they become unglued from the bowl of the toilet.

Based on record reviews, observations, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to ensure blood glucose meter controls were being performed daily. This failed practice had the potential to impact 2 out of 2 (#5 and #R1) current diabetic patients on Unit 300 receiving sliding scale insulin out of a total sample of 6 (#1-#5, #R1).

Findings

Review of the hospital's policy titled Glucometer Method for Obtaining CBGs, revealed in part, Confirm System Performance/Control test: a control test confirms that the system is functioning properly. Control tests are to be performed every 24 hours of patient use and anytime there is a question about the blood glucose test results.

Review for the Glucose Control Log Sheet for April 2022 for Unit 300 revealed the 24 hours glucose controls were not performed on 04/02/2022, 04/03/2022, 04/04/2022, 04/07/2022, 04/08/2022, and 04/09/2022.

Patient #5
Review of the Patient #5's History and Physical, dated 04/06/2022, revealed the patient has a diagnosis of Diabetes mellitus. With further review of the patient's History and Physical revealed Diabetes mellitus with coincident hypertension hemoglobin A1c was greater than 14 in December 2021. Patient obviously noncompliant with insulin treatment. Monitor CBGs here and provide sliding scale insulin as needed.

Review of the Patient #5 physician order dated 04/06/2022 revealed an order for Capillary Blood Glucose AC and HS. Patient #5's room was located on Unit 300.

Patient R1
Review of Patient R1's History and Physical, dated 04/06/2022, revealed a diagnosis of Diabetes Mellitus. With further review of the History and Physical revealed Type 2 Diabetes mellitus with hyperglycemia, with long term current use of insulin-continue Levemir and Novolog as currently scheduled.

Review of Patient R1's physician orders, dated 04/05/2022, revealed an order for Capillary Blood Glucose AC and HS. Patient R1's room was located on Unit 300.

An interview was conducted with S2DON on 04/11/2022 at 10:30 a.m. S2DON reported it is the night nurses responsibility to conduct the glucose controls every 24 hours. She confirmed in April 2022 the glucose controls have not been conducted every 24 hours on Unit 300.