HospitalInspections.org

Based on interviews and document review, it was determined the facility failed to have a policy or procedure for the use of locked doors in patient rooms and it was determined the facility failed to provide an environment free from ligature risk.

The findings include:

On 8/2/2021, the surveyor toured the adolescent unit and unit C, an acute care adult unit of the facility with SM #4. SM #4 stated that the patient room doors on the adolescent unit lock when the door is closed. SM #4 stated that staff must use a key to unlock the patient door from the outside but that patients are able to open the door from the inside without having to unlock them. SM #4 borrowed a key from the unit nurse to unlock the door to an empty patient's room for viewing by the surveyor.

During an interview on 8/2/2021, SM #16 stated that "we don't want them [adolescent patients] in the rooms" during the day so the doors lock to keep them out of their rooms. SM #16 stated that the patient room doors should not be closed when the "kids" are in the rooms.

During an interview on 8/2/2021, SM #5 stated that doors on the new unit can be locked or unlocked and it can always be opened from the inside without unlocking. SM #5 stated that the adults have more freedom and could have the door closed and locked from the outside while in the room.

During an interview on 8/2/2021 at 3:55 p.m., SM #7 stated that the Mental Health Techs (MHT) and nurses have a key to unlock the patient doors. SM #7 stated that patients would get annoyed with the key unlocking the door at night while they were sleeping during the fifteen (15) minute checks. SM #7 stated that this was a reason why the patients or staff would drape a towel over the top of the door, to keep the door from locking and to prevent the light from the hall from coming in their room, prior to 11/26/2020. SM #7 stated that it was common practice to have a towel draped over the top of the door to prevent the door from closing all the way, so patients could get back into their rooms without waiting for it to be unlocked.

During an interview on 8/4/2021, SM #7 stated that there are no policies or procedures related to the doors being locked for patient rooms.

On 8/2/2021, the surveyors toured the facility with Staff Member (SM) #4. While touring the adolescent unit of the facility, the surveyors entered the group/meal room with SM #4, the door was completely open and the light was on. The surveyor observed multiple cords hanging down from the back of the large screen television that was mounted on the wall in that room, that was located near the nurse's station. The plug end of the cords were not hanging down as they had looped back up behind the television. The cords were easy to reach and SM #4 attempted to push them up behind the back of the television, but they just dropped back down.

During an interview on 8/2/2021 around 1:00 p.m., SM #4 stated that it was a group room and that the patients are "never in there by themselves."

It was found the facility does not have a specific policy related to ligature risk although the surveyor was advised the physical environment utilizes as many ligature-resistant features as possible based on the standard of care for psychiatric patients.