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GRAND LAKE HEALTH SYSTEM
PATIENT RIGHTS
Tag No.: A0115
Based on observation and interview, the facility failed to ensure care was provided in a safe setting for patients on the geriatric psychiatric unit related to ligature risks. Each room had ligature risks of a door with four hinges and a bed containing four side rails, a headboard, a footboard, an electrical cord to a motor that raised and lowered the bed frame and three hinges to raise and lower the head and foot of the bed. (A144) The census was four and the unit had a capacity of 12 patients. This had the potential to affect all patients who either were suicidal or became suicidal during their stay on the geriatric psychiatric unit.
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on observation and interview, the facility failed to ensure care was provided in a safe setting for patients on the geriatric psychiatric unit related to ligature risks. This has the potential to affect any patient residing on the unit. The facility had a census of four patients during the survey. The capacity of the unit was 12.
Findings include:
On 02/07/19 at 10:45 A.M. a tour was taken of the geriatric psychiatric unit with Staff A. The tour revealed each of the 12 rooms contained ligature risks of a door with four hinges and the same type of bed: a standard hospital bed with a motorized frame containing small holes, the ability to raise and lower, three hinges to raise and lower the head and foot of the bed and an approximate two foot electrical cord from the motor to the outlet. The bed was observed to have a headboard, footboard, and side rails that could be raised and lowered. Staff A confirmed the presence of the ligature risks during the observation.
During the tour, patient rooms were observed without direct supervision of staff. Video monitoring was in place to monitor the hallways and common areas in general, and to ensure all rooms with a patient assignment had open doors and those without patients, closed doors. Observation of the video monitoring revealed blind spots at patient rooms 574 and 501.
Staff A verified the presence of the ligature risks at the time of the observation.