HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when:
- Staff failed to recognize and remove ligature (anything which could be used for the purpose of hanging or strangulation) risks located on the Geriatric Behavioral Health Unit (BHU) for four current patients (#7, #32, #33, and #51) admitted with suicidal ideations (SI, thoughts of causing one's own death).
- Patients were allowed unsupervised access to contraband (items that are illegal, forbidden, or that can be used to harm self or others) throughout patient rooms, bathrooms, and common rooms on three out of four behavioral health units observed.
- The electrical wall receptacles were left open, without secure coverings, throughout three out of four BHU's observed.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights and placed all patients admitted to the hospital at risk for their health and safety. The hospital census was 166, with 72 patients located on four BHU's.

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting by ensuring that:
- Medical bed power cords were not longer than 18 inches to prevent ligature (anything which could be used for the purpose hanging or strangulation) risk and self-harm (behavior that is harmful or potentially harmful to oneself) for four current patients (#7, #32, #33, #51) on Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) who were admitted to the Geriatric Behavioral Health Unit (BHU). All 19 medical beds on this unit had power cords that were over 18 inches in length.
- Contraband (items that are illegal, forbidden, or that can be used to harm self or others) was not accessible to patients on the BHUs. Contraband items were found in patient rooms and dayrooms located on the Geriatric, Adolescent and Adult BHUs, and were accessible to the patients.
- Electrical wall receptacles were not securely covered throughout the Geriatric and Adolescent BHUs, which may allow patients to stick contraband items into and cause patient harm.

These failures placed all patients admitted to the hospital at risk for their health and safety by not providing a safe environment under 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights. The hospital census was 166, with 72 patients located on the BHUs.

Review of the hospital's policy titled, "Suicide (to cause one's own death) Prevention for Patients in Inpatient Psychiatric (relating to mental illness) Units," revised 10/19/21, showed that patient rooms and bathrooms should be free of ligature (anything which could be used for the purpose of hanging or strangulation) risks and that any psychiatric medical beds used must have the electrical cord shortened to the shortest possible length.

Review of the hospital's document dated 06/14/22, titled, "Bed power cord length," for the psychiatric unit, showed 21 beds listed with two non-medical beds and 19 medical beds that had a power cord. Of the 19 medical beds, one cord length measured 18 inches and 18 of the beds measured between 23 and 31 inches in length.

Review of the hospital's untitled document dated 06/14/22 at 9:47 AM, showed that four of five patients on Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were admitted to rooms containing medical beds with electrical cords measuring greater than 18 inches in length:
-Patient #7, an 86 year old female was admitted to room 200.
-Patient #32, a 71 year old male was admitted to room 202, bed one.
-Patient #33, a 71 year old male was admitted to room 202, bed two.
-Patient #51, a 79 year old female was admitted to room 208, bed two.

Review of the hospital's policy titled, "Suicide Prevention for Patients in the Emergency Department," revised 05/12/21, directed staff to remove all sharps, contraband, unnecessary equipment, items that could be used as weapons, and to ensure that all soap and/or hand sanitizer was out of reach of the patients.

Review of the hospital's document titled "Patient Safety Assistant (PSA) Guide: Patients at Risk for Suicidal/Homicidal Ideations," directed staff to remove potentially dangerous items from the room such as items with cords, disinfecting wipes, extra linens, sharps instruments, soaps and hand sanitizers.

Review of the hospital's policy titled, "Patient Valuables and Belongings," dated 05/12/21, defined contraband as any item that could potentially pose a safety risk to the patient, staff, and/or visitors.

Review of the hospital's St. Louis Region policy titled, "Behavioral Health Services Prohibited Substances Contraband Control," reviewed 09/2021, showed that hand sanitizers and toiletry items were not allowed on the BHU's and would be secured or sent home.

Review of the hospital's document titled, "Welcome & Unit Guidelines," dated 04/05/22, showed that the Adult Behavioral Health Unit (ABHU) prohibits personal hygiene products on their unit.

During an interview on 06/14/22 at 9:15 AM, Staff N, Senior Behavioral Health Unit (SBHU) Manager, stated that rooms were always open to allow patients access to their beds, except for the patients on one to one observation (1:1, continuous visual contact with close physical proximity).

During an interview on 06/14/22 at 9:45 AM, Staff N, SBHU Manager, stated that her unit did not have any type of unit guidelines to provide to her patients that would inform them of the items that were prohibited on the unit.

Observation on 06/13/22 at 2:45 PM, on the SBHU, in Patient #4's room, showed:
-The electrical wall receptacles were open, without a secure covering attached.
-A medical bed plugged into the electrical wall receptacle with a power cord measuring 25 inches in length.
-Numerous contraband items sitting on the bathroom sink, to include two foam soap bottles (four ounces), a tube of denture adhesive (two ounces), three deodorant bottles (one and half ounces), three body wash bottles (four ounces), and one white plastic fork.

Observation on 06/13/22 at 2:50 PM, on the SBHU, in Patient #36's room, showed:
-The electrical wall receptacles were open, without a secure covering attached.
-Two medical beds plugged into the electrical wall receptacle with power cords measuring 26 inches and 23 inches in length.
-Numerous contraband items including one foam soap bottle (four ounces) and one body wash bottle (four ounces) sitting in the shower; two bottles of body wash (four ounces), one bottle of lotion (four ounces), and one plastic bath in a bag sitting on the bathroom sink.

Observation on 06/13/22 at 3:05 PM, on the SBHU, in Patient #5's room, showed:
-The electrical wall receptacles were open, without a secure covering attached.
-One medical bed plugged into the electrical wall receptacle with a power cord measuring 24 inches in length.
-Numerous contraband items including one body wash bottle (four ounces), one bottle of lotion (four ounces), one tube of protective ointment (two ounces), one bottle of deodorant (one and one half ounces), and one toothbrush sitting on the bathroom sink.

Observation on 6/15/22 at 8:34 AM, on the ABHU, in Patient #56's room, showed numerous contraband items, on the sink, a brown paper bag that included several personal care items, such as toothbrush, mouthwash, and liquid soap; and the electrical wall receptacles were open without a secure cover attached.

Observation on 6/15/22 at 8:35 AM, on the ABHU, in Patient #57's room, showed numerous contraband items including, on the sink, a plastic spoon in a paper cup; and the electrical wall receptacles were open without a secure cover attached.

Observation on 6/15/22 at 9:23 AM, on the Adolescent BHU, in Patient #58's room, showed numerous contraband items including, on the sink, a toothbrush and in the shower, two small bottles of liquid used for cleaning a patient's body; and the electrical wall receptacles were open without a secure cover attached.

Observation on 6/15/22 at 9:24 AM, on the Adolescent BHU, in Patient #59's room, showed numerous contraband items including, on the sink, a toothbrush and a plastic comb; and the electrical wall receptacles were open without a secure cover attached.

During an interview on 6/15/22 at 8:35 AM, Staff UU, ABHU Manager, stated that every adult room had personal care items left out unless the patient was known to self-harm (behavior that is harmful or potentially harmful to oneself).

During an interview on 06/13/22 at 2:45 PM, Staff O, RN, stated that:
-Patients on the SBHU were allowed to have toiletries in their room.
-20 of the 22 beds on the SBHU were psychiatric medical beds with power cords.
-The bed controls, for raising and lowering the bed, were easily accessible at the foot of the bed.

Although requested on 06/15/22 at 9:40 AM, the hospital failed to provide a policy related to the inventory of patient silverware for the BHUs.

Observation on 06/14/22 at 9:25 AM, SBHU dayroom, showed multiple patients walking around the unit, in and out patient rooms, back to the common room and a paper cup, with several plastic utensils, sitting on the counter, unattended by staff members.

During an interview on 6/15/22 at 8:40 AM, Staff SS, Director of Nursing (DON), stated that the hallways were monitored every 15 minutes so there was no concern with patient doors open and patients that wandered.

Observation on 6/15/22 at 8:23 AM, in the ABHU dayroom, showed multiple breakfast trays were stacked with plastic eating utensils visible.

During a concurrent interview on 6/15/22 at 8:23 AM, Staff N, Behavioral Health Unit 2A Nurse Manager and Staff SS, Behavioral Health DON, stated that the plastic eating utensils would have bent and not have broken; staff had not counted the plastic eating utensils when trays were returned after meals.

During an interview on 06/14/22 at 9:15 AM, Staff BB, Patient Sitter, ED, stated that food service staff counted the silverware when they picked up the food tray.

During an interview on 06/14/22 at 3:15 PM, Staff QQ, Adolescent BHU Manager, stated that:
-They keep the patient's personal hygiene items in a bin and provide them with the items during their designated shower time but, they did not allow the patient's to keep the items in their room.
-Counting patient's eating utensils was performed at meal times and was covered in the onboarding process.
-Staff members float between the campuses, if necessary, to provide staffing.

During an interview on 6/15/22 at 9:25 AM, Staff QQ, Adolescent BHU Manager, stated that toothbrushes, combs, and mouthwash were all allowed to stay in a patient's room and shampoo and soaps were to have been placed in a bin and returned.

During an interview on 06/14/22 at 9:45 AM, Staff N, SBHU Manager, stated that:
-Patients were provided with plastic silverware on their meal trays and that staff members do not count or account for the utensils when staff pick up the trays.
-The medical beds on the SBHU were supposed to be psych safe because they had shorter cords. She was not aware of the actual lengths and had not measured them.
-Patients were allowed to have toiletries in their rooms and she was not aware of the procedure in the other BHUs.

During an interview on 06/15/22 at 11:00 AM, Staff K, Chief Nursing Officer/Vice President Nursing, stated that she would expect her BHU's to be safe for the patients, free of ligature risks and direct access to contraband items.










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