HospitalInspections.org

Based on review of documentation, policies/procedures, patient, patient family, and staff interviews, the facility failed to implement systems that assured a safe and functional environment for patients with a psychiatric diagnosis in all patient care areas. The facility had a census of 18 inpatients on the Adult Male ward R, 12 inpatients on the Adult Female ward 21, and 8 inpatients on the Child and Adolescent ward T.

Although facility staff was aware of the conditions that posed a risk to patients with psychiatric diagnoses, some of whom were suicidal, the facility failed to:

-Ensure contraband was not available to patients.

-Follow facility policy for monitoring patients on precautions and failed to follow policy for using radio contact with staff when monitoring patients.

-Identify and/or remove or replace non-breakaway hardware and/or exposed plumbing from the patient shower rooms, bathrooms, and doors.

-Maintain a safe environment for suicidal patients by failing to minimize risk factors available in patient bedrooms, hallways, dining room; and

-Maintain a safe environment for suicidal patients by failing to minimize other risk factors available in patient bedrooms, bathrooms, and shower rooms.

(Refer to A144)

Providing a physically safe environment and an effective system of monitoring patients with psychiatric diagnoses and/or suicidal tendencies is extremely important in maintaining patient ' s safety. Staff vigilance in monitoring the patients' whereabouts and behavior while on precautions is critical in order to prevent these patients from harming themselves and/or other patients.

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of patients, with psychiatric diagnoses who may also be suicidal, in a safe environment.

I. Based on review of policies/procedures, medical record, observations, staff, patient, and family interviews, the facility failed to establish and maintain a safe environment for 1 of 1 (Patient #1) patient who had a history of multiple suicide attempts by hanging prior to admission and attempted suicide by hanging while a patient in the facility. Additionally, the facility had identified and documented 2 additional incidents where patients (Patient #3 and 6) had attempted hanging and 2 incidents where two patients (Patient #7 and 8) attempted asphyxiation by tying a sheet around their neck. Census at the time of the investigation was: Adult Male ward R, 18; Adult Female ward 21, 12; and Children and Adolescent ward T, 8.

Failure to establish and maintain a safe environment and system for monitoring patients with a psychiatric diagnosis could potentially result in patient deaths or other life-threatening conditions and did result in 1 patient's attempt to commit suicide by hanging.

Findings include:

1. Review of "Accident Or Unusual Event" report, dated 7/18/12 at 3:00 PM, revealed in part:

- "Give Description of the incident: ...[Staff C,] Resident Treatment Worker [RTW] found patient [#1] sitting on the floor in the back bathroom stall with a belt looped around [the Patient's] neck and through the stall frame. Staff immediately removed belt and lowered [the Patient] to floor and sent radio message that help was needed now. Code blue called at 1500 [3:00 p.m.] Patient dusky but had pulse ....

- "Ward Nurse/Supervisor ' s Report Severity Index: showed injury, medical intervention required ...sent to ER [Emergency Room] for exam due to nature of event. ...

- "Interventions completed by RN [Registered Nurse] Supervisor: patient lowered to floor emergency bag brought to area, oxygen applied at 15 liters per non re-breathing mask. Vitals at 1507 [3:07 p.m.] BP [blood pressure]-90/48, p [pulse]-84, R [respirations]-20 color improving and pulse oximetry [device that measures the amount of oxygen in the blood] at 99%. [Physician A] arrived on unit. Patient became more responsive, stated [patient] was ok and Emt [Emergency Medical Team] arrived and transported to [local hospital] ...

- "Doctor's Report: per [Physician A] transport to [local hospital] for further evaluation ..."

(A "code blue" means staff were to report to the location immediately where a patient had a serious and potentially life-threatening change in medical condition).

2. Review of Patient #1's medical record revealed the following, in part.

-Review of the "Patient Responsibility Form" found it identified all of Patient #1's belongings at the time of admission, dated and signed by Patient #1 on 3/21/12. The document showed Patient #1 did not have a belt at the time of admission.

-On 3/15/12 an Iowa District Court order showed Patient #1 required inpatient therapy because the patient was seriously mentally impaired and in need of full time care. The Court Order showed the Sherriff would transport the patient to Mental Health Institute (MHI) in Independence on 3/21/12. The Patient's medical record showed MHI staff admitted Patient #1 to Adult Male Ward R on 3/21/12 after the patient attempted to commit suicide by hanging with an electrical cord at the Patient's previous location, a Residential Care Facility (RCF).

-Review of periodic court evaluations, used to determine the Patient's need for continued inpatient therapy, revealed that on 4/9/12 the Patient continued to feel depressed at times, had an extensive history of suicidal thoughts and gestures, lacked insight, and his judgment was impaired.

-Review of the Psychiatric Nursing Assessment on the Admitting Nursing Notes, dated 3/21/12 at 12:10 PM, showed the Patient's reason for admission was "Suicide". The Patient's understanding of the reason for this hospitalization was because, "I tryed [sic] to commit suicide I was depressed, I tryed [sic] to hang myself." Patient #1 admitted to being impulsive and had tried to harm himself in the past. Additional documentation on the Psychiatric Nursing Assessment on the Risk of Violence to Self section revealed, "During the previous 6 months has the client experienced any of these issues?... Suicidal thoughts suicide plan suicide attempts intentional cutting, burning, or other self harm." Patient #1 admitted to attempting to hang, as well as, burn himself.

-Physician B's (Patient #1's primary psychiatric physician) Initial Treatment Plan dated 3/31/12 revealed Patient #1 had a long standing history of mental illness and having a tendency to become self-abusive (hurt himself).

-Physician B's Admission Intake note dated 3/21/12 revealed the Patient became suicidal while at the RCF and required psychiatric hospitalization at another hospital on 3/10/12. The hospitalization occurred after the Patient had felt suicidal and attempted to strangle himself with an electrical cord. The Patient had made several suicide attempts by overdose of pills, cutting, and strangling.

-Social Service intake note dated 3/23/12 showed, in the past year, the Patient had multiple hospitalizations due to self-inflicted injuries that included cutting and hanging.

In the past, the Patient's close relative has stated concern that at some time, due to his impulsive behaviors, the Patient will act on a suicidal gesture, not with a plan to end his life, but fears that is what will ultimately end up happening.

-Patient #1's Nursing Care Plan dated 3/22/12 showed the following Nursing Diagnosis: ineffective individual coping related to the patient's poor insight and judgment and attempts to strangle himself. Patient Goal was the patient would make no gestures to harm himself. Staff activity and interventions included, in part, "Provide constant observation whenever patient is on precautions and remove potential dangerous items from patient's environment that could be used to harm self or others."

-Patient #1's Nursing Care Plan dated 4/12/12 showed the Patient was on "sexual precautions". (Sexual precautions are imposed when staff believe a patient, if left unsupervised, will sexually harm, exploit or assault other people.) Interventions initiated included, "8 d. constant observation/supervision e. Must use bathroom or tub room alone ...9 e. Direct staff supervision of bathroom and bathing. Patient to obtain staff permission ... "

Review of hospital policy for sexual and assault precautions, revised 11/2009, found it requires nursing and/or designated clinical staff to have constant direct supervision which cannot be broken without proper relief (i.e., one person is relieved and another person is assigned the responsibility). In the event one of the patients leaves the room, it is the responsibility of the staff observing them to summon an additional staff to observe the patient who has left the room. When precaution status is discontinued, by written order of the physician, all nursing staff and the affected patient will be immediately informed.

-Review of the Physician Order Sheet revealed the following, in part.

On 6/25/12 at 9:15 PM, Physician A gave a telephone order to nursing staff to observe Patient #1 on assault precautions.

On 6/19/2012 at 2:30 PM, a physician ordered sexual precautions for Patient #1.

-Review of patient progress notes (a form in the medical record where all disciplines document patient information), dated from 6/15/12 through 7/18/12, revealed Patient #1 continued on assault and sexual precautions as needed when the Patient acted out either in a physical or sexual manner.

Patient #1 continues on sexual precautions. Physician B discontinued assault precautions on 7/18/12 at 1:40 PM. However, nursing staff failed to note the order to discontinue assault precautions and did not notify all nursing and designated clinical staff of the order until 7:32 PM, after the hanging incident. Patient #1 was on sexual and assault precautions at the time of the hanging incident on 7/18/12.

-Review of Nurses Notes dated 6/23/12 at 2:55 PM, showed Residential Treatment Worker (RTW) R documented that Patient #1's close relative phoned to voice concerns about the Patient's behavior stating the relative thought the Patient has totally given up. The close relative was also concerned that the Patient had a belt.

3. During an interview on 8/21/12 at 10:05 AM, Patient #1 reported not having a belt upon admission to the ward. The Patient would not reveal how he obtained the State issued belt, but admitted having the belt in his possession for "a while" and staff was not aware he possessed the belt.

4. During an interview on 8/21/12 at 1:00 PM, Patient #1's close relative said he/she did not recall whom he/she told, but told staff, a month prior to the incident that occurred on 7/18/12, that the Patient wasn't acting right and he/she was afraid he was going to harm himself because of prior attempts. The relative reported telling staff Patient #1 had a belt that the hospital staff had provided to keep his jeans up. The Patient told the relative he hid the belt under his mattress. The close relative told staff to take the belt from the patient and reported that seven years ago the Patient had attempted to hang himself using a belt. More recently, the Patient had used an electrical cord to attempt hanging, and had put a plastic bag over his face to attempt asphyxiation. According to the close relative, each of these incidents occurred in an institution of some sort. The relative further stated he/she assumed staff would remove the belt.

5. During an interview on 8/24/12 at 11:00 AM, RTW R acknowledged taking a call from Patient #1's close relative on 6/23/12. During the call, the relative was very concerned about the Patient's well-being stating, the Patient had told him/her that he had totally given up, was depressed, that he had a belt and the relative was afraid the Patient would harm himself. The relative did tell RTW R the Patient told him/her that he had a belt and that Patient #1 had tried to hang him self, using a belt, in the past.

When asked if RTW R conducted a search for contraband in Patient #1's room upon the report of the Patient having a belt, RTW R said no and acknowledged that she should have conducted a search for contraband. According to RTW R the facility policy requires staff to conduct a search for contraband anytime staff suspects or has knowledge of contraband in a patient's room or on their person. RTW R said she had received training in how to conduct a search. Review of RTW R's personnel file showed training on the policy for searches, completed on 10/31/11. RTW R reported conducting a contraband search would include looking under the mattress, in the wardrobe, on the patient's table, in the bathrooms, and in the day room. RTW R said they no longer conduct random searches of the ceiling tiles; they stopped doing that a couple of years ago. RTW R said some of the things the facility considered contraband included cigarettes, lighters, razor blades, kitchen utensils, and pop cans.

-Registered Nurse (RN) S documented the following in Patient #1's chart on 6/23/12 at 4:05 PM, after report from RTW R regarding Patient #1's close relative's phone call where he/she relayed concern that the Patient was going to harm himself with a belt. After receiving the report from RTW R, she went to Patient #1's room and completed a self-harm suicide risk assessment. The documentation showed Patient #1 denied thoughts of self-harm or suicide. According to the Patient, his temper had been at an all time high. RN S documented the following interventions: encouraged communication between the Patient and his close relative and try to reassure him/her sometime this evening.

6. During an interview and review of Patient #1's medical record on 8/28/12 at 3:20 PM, RN S reported that she had completed a suicide risk assessment because RTW R reported a conversation she had with the Patient's relative as noted in the medical record. RN S did not conduct a search of the Patient's room for contraband after completing the suicide risk assessment and did not contact the Patient's close relative for additional information. RN S stated contraband items might include lighters, matches, stashed cigarettes, and pieces of plastic. RN S confirmed the Patient was in a precaution dorm (i.e., it requires nursing and/or designated clinical staff to have constant direct supervision, which cannot be broken without proper relief.) and the facility does not allow belts in the precaution dorms. RN S said, looking back, she would have done things differently and agreed she should have searched the Patient's room for contraband and called the Patient's close relative.

RN S stated she was not familiar with the facility policy and procedure for searches and did not recall receiving annual training related to the facility search policy. Review of
RN S's personnel file showed training on the policy for searches, completed on 10/31/11.

-Review of the facility's "Policy for Searches", dated 10/2011, revealed the following in part, Staff conducts searches to provide safety and security to the patients and staff. If staff suspects a patient has contraband or unsafe items, they will complete a search of the patient, their belongings, and the environment including a patient's room and/or the unit.

-Review of facility policy titled "Radio Policies", revised 4/8/11, revealed the following in part, "The hospital policy for the use of the hand held and a mobile (switchboard) radio is to aid with daily ongoing communication and the request for assistance in emergency situations .... Staff will be issued hand held radios for daily communication and emergency usage ....Radio shall be worn, shall be operational, and shall be at an audible volume level at all times ...During the beginning of a shift, a radio will be issued to each staff member. Each ward will have a designated sign-out and check-in process. Use of Radios ....At the end of a short message, acknowledge such as '10-4', 'Thank You', or 'Okay'."

7. During an interview on 8/21/12 at 7:50 AM, RN H/Supervisor of the male and female adult wards, stated when facility staff enter the male and/or female units, at the beginning of the shift they are educated and trained to obtain a hand held radio before they enter the unit. RN H acknowledged when Patient #1 attempted to hang himself in the back bathroom on the men's ward, RTW U and RTT B failed to follow facility policies for sexual and assault precautions, as well as the facility's radio policy and they received verbal counseling on 7/21/12 from supervisory staff.

8. During an interview on 8/22/12 at 12:40 PM, RTW W reported that he works on the Adult Male ward R and was on duty at the time Patient #1 attempted to hang himself in the bathroom. According to RTW W, Patient #1 was on sexual precautions. When a patient is on sexual precautions, staff is required to go into the bathroom to ensure no patients are in the bathroom then stay in close proximity to make sure no other patients enter the bathroom.

Staff uses the radios to summon help and staff is required to check them out at the beginning of their shift. We had thorough education prior to initiating their use about a year ago. We are trained to respond to the radio should staff summon for help. I heard RTW B announce on the radio that Patient #1 wanted to go back to his dorm. RTW B would not have directed the call towards me because I was at the end of my shift and was giving the end of shift report. At that time of day, I assumed the call was for RTW U because he was in the dorm Patient #1 wanted to enter. At that time of day, all RTW staff should have had their radios on and in their possession.

9. During an interview on 8/23/12 at 8:55 AM, RTW U reported he gets a radio at the beginning of each shift and if no radio is available, "I will call, by phone, to other wards to get one." During an interview at 3:00 PM, RTW R stated he entered the men's ward on the day of the hanging incident (7/18/12) at approximately 3:00 PM. RTW U acknowledged he failed to obtain a hand held radio prior to entering the ward because there were none in the basket and in "hind" sight he should have.

RTW U was assigned to dorm B but he did not recall seeing Patient #1 entering dorm B that day. However, he did recall the "yelling and commotion" in the back bathroom and was aware that Patient #1 had attempted to hang himself. RTW U did not recall entering the back bathroom but did remember securing the dorm area while multiple staff provided medical emergency assistance to Patient #1. RTW U stated he received verbal counseling from RN H on 7/21/12 related to his failure to obtain and carry a hand held radio while on duty.

-Review of RTW U ' s personnel file showed training for the use of hand held radios on 2/21/11, training for facility policies and procedures for sexual precautions on 9/6/11, and safety training on 10/1/11.

10. During an interview on 8/22/12 at 4:15 PM, Plant Operations Staff F stated there are 11 spare radios stored in the communication room should staff need a radio. It would not be difficult to get another radio at any time.

11. During an interview on 8/24/12 at 8:35 AM, Resident Treatment Technician (RTT) B reported his assignment on the day of the incident was observing patients in the day room; this included Patient #1 from 9:00 to 10:00 AM and 2:00 to 3:00 PM. He did acknowledge that if patients were on assault precautions staff were responsible for knowing where they were and have visual contact with these patients at all times. Additionally, for patients on sexual precautions, staff must check the bathrooms before a patient enters and stand outside the door to make sure no one else goes in the bathroom. RTT B recalled, on 7/18/12 at 3:00 PM, seeing Patient #1 walking down hallway B. He asked the Patient if he was going to rest, but the patient never answered him. RTT B said that Patient #1 walked past the front bathroom and stopped when he got to the back bathroom (bathroom B 15), glanced in and hesitated for a moment but he did not see the Patient enter the bathroom. RTT B said he could see RTW U standing in the hallway to dorm B. Following this observation, RTT B alerted RTW U, through the hand held radio, that Patient #1 was entering dorm B (the Patient's room was approximately 10 feet inside the door to dorm B). RTT B then turned his back to the hallway and focused on the day room again. RTT B reported that he did not receive a response to his radio message from RTW U and did not follow-up on this to assure that RTW U received the message and knew that Patient #1 had entered dorm B and if the Patient was in RTW U's sight. He did acknowledge that he was not following the facility's radio, sexual, and assault precautions policies. RTT B reported he had received training in the use of radios. RTT B stated he received verbal counseling from RN H on 7/21/12 related to his failure to follow facility policies regarding handoff of a patient on sexual and assault precautions from one staff to another.

Review of RTT B's personnel file showed training for the use of hand held radios on 2/21/11, training for facilities policies and procedures for sexual precautions on 9/6/11, and safety training on 10/1/11.

12. During an interview on 8/23/12 at 4:30 M, RTW C stated he entered the men's ward on the day of the hanging (7/18/12) at approximately 2:40 PM. He completed roll call (accounting for the whereabouts of every patient) and remembered seeing Patient #1 in hallway A at 2:40 PM. He also recalled seeing RTW U in dorm B sitting at the nurse's desk (a desk used by facility staff to view patient's directly when they are in their dorm rooms. Additionally, the nurse's desk is located immediately outside Patient #1's bedroom allowing staff to view Patient #1 when he is in his dorm room) at 2:50 PM. According to RTW C, "around" 3:00 PM, Patient #9 came up to the nurse's station and said Patient #1 "is doing something funny" in the bathroom. RTW C went down B hallway to the back bathroom. He stated the bathroom stall Velcro curtains were closed but he could see Patient #1's legs and calves extending below the front of the curtain and the Patient's buttocks were raised off the floor. He entered the bathroom and asked the Patient, "What are you doing?" When the Patient did not respond, he recalled seeing a belt wrapped through a stall bracket so he pulled back the curtain and saw the belt looped around Patient #1's neck "like a noose" and the other end of the belt was "wedged" behind the top stall bracket. RTW C called for help on the hand held radio and then supported the Patient's neck while he jerked the belt to release it from the anchor point on the bathroom stall bracket then eased the Patient to the floor and removed the belt from the Patient's neck. RTW C reported that the patient's eyes were closed and his hands and arms were shaking uncontrollably. RTW C stated Licensed Practical Nurses (LPNs) and RNs started coming into the bathroom and he stepped back to allow the nurses to provide care and emergency services to the patient.

13. Additional interviews conducted throughout the investigation regarding use of hand held radios, sexual precautions, and assault precautions revealed:

-During an interview on 8/21/12 at 7:50 AM, RN H, stated direct patient care staff received education regarding hospital policies for using hand held radios and monitoring patients on sexual and assault precautions. RN H explained a physician's order is required to initiate and discontinue sexual and assault precautions. RN H reiterated staff is never to lose sight of patients on sexual and assault precautions and know that the minute staff enter a patient care ward they are suppose to have a hand held radio in their procession to assure communication with other staff members on the ward and for medical emergencies.

-During an interview on 8/21/12 at 3:15 PM, RTW V said she primarily works on the Adult Male ward R and Adult Female ward 21, and everyone that works at the facility must pick up a radio when they get on the ward.

-During an interview on 8/22/12 at 6:50 AM, RN G reported that he works on the Adult Male ward R and Adult Female ward 21. RN G said, regarding sexual precautions, staff is educated to know where a patient on precautions is located at all times. Patients on sexual precaution are educated to come to nursing or RTW staff when they need to use the restroom. Staff checks the restroom to ensure no other patients are in the restroom before the patient on precautions enters; then staff waits outside the door for the patient, to ensure no other patients enter. Additionally, RN G stated nursing and RTW staff are educated to sign out a radio located in a basket immediately inside the nurse's station on each ward.

-During an interview on 8/22/12 at 10:00 AM, RTW D reported she worked on all 3 wards (Adult Male R, Adult Female 21, and Children and Adolescent ward T). RTW D was in the nurse's station on the Adult Male ward R on the day of the hanging incident (7/18/12). According to RTW D, when monitoring patients on sexual precautions staff are required to check the bathroom before the patient enters and stay in the general area to see that no other patients enter the bathroom. Regarding radio use, RTW D said all staff is educated that once the shift starts, they should have a radio, which is use to communicate with staff.

14. Additional document review showed the facility had identified and documented 2 additional incidents where patients had attempted hanging and 2 incidents where patients attempted asphyxiation by tying a sheet around their neck.

-Review of Patient #6's medical record showed the patient admitted on 5/7/12 to the Adult Male ward R. "Admission/Ward Physician's Intake Note", dated 5/7/12, revealed the patient had suicidal ideation, was depressed, and admitted suicidal ideation of cutting or strangling himself. Nurse's notes dated 7/16/12 at 12:30 PM revealed, in part, "Went to [ward] B dorm door-Tied his shoe strings together-Then tied them around dorm door knob and his neck. Peers came to dayroom asking staff to come-[patient] found [with] shoe strings loosely around his neck ..."

Review of "Accident Or Unusual Event" report dated 7/16/12 at 12:30 PM for Patient #6, revealed in part, "Give description of the Incident: Pt [patient] tied his shoelaces to dorm B dorm door and around his neck ...Interventions completed by RN/Supervisor: Red mark around neck. Absolutely no respiratory distress ... "

-Review of Patient #7's medical record showed the patient admitted on 12/20/11 to the Adult Male ward R. "Admission Criteria" form showed the patient was a danger to himself with self-injury and suicide potential. "Ward Physician's Intake Note" dated 12/21/11 revealed in part, "The patient has at times become self-abusive and made suicidal attempts as well as suicidal threats."

Review of facility "Accident Or Unusual Event" report dated 1/1/12 at 6:10 PM for Patient #7, revealed in part, "Give Description of the incident: ...Patient found during routine rounds (roll call) [with] sheet tied around his neck several knotts [sic] (x3).

-Review of Patient #3's medical record showed the patient admitted 7/23/12 to the Children and Adolescent ward T. "Ward Physician's Intake Note", dated 7/23/12, revealed, in part, the reason for the patient's admission was due to suicidal threats and gestures and the patient had been reporting a suicidal plan to suffocate them self by inhaling water. The patient had tied a string around their neck and had tried to choke them self with their hands on 7/18/12 and was taken to another hospital's Emergency Department for treatment. The patient also reported being extremely impulsive and has a very poor frustration tolerance which causes a lot of angry acting out.

Review of facility "Accident Or Unusual Event" report, dated 8/9/12 at 8:05 PM for Patient #8, revealed, in part, "Give Description of the incident: pt had green tape (used for rec) loosely wrapped around neck and was reaching up to throw it around metal grid used to support ceiling tile, when RTW walked up to pt [the patient] took tape and threw it at RTW, no marks noted ... "

-Review of Patient #8's medical record showed the Patient admitted 4/14/08 to the Adult Female ward 21. "Admission Note", dated 4/14/08, revealed, in part, "Although this patient is on numerous medications to address her mood and behavior problem, it appears that she was posing a danger to self which has resulted in her admission to MHI, Independence. The "Behavioral Health Reassessment-Day/Evening Shift" form dated 4/15/12 revealed, in part. " Pt spitting at nurse and pounding on office windows, rolling eye back in head. Pt also riped [sic] sheet on bed and put it around neck and spit on ward RN. Pt was put in 5 point restraints to prevent harm to self and others .... " (5 point restraints means a restraint applied to each arm, each ankle, and the chest-waist.)

Review of facility "Accident Or Unusual Event" report for Patient #8, dated 4/15/12 at 8:45 PM, revealed, in part, "Give Description of the Incident...tore up her sheet and tied it around her neck Pt started pulling it and writer could only get fingers in until RN got back to help [with] her RN got there pt let go of it and layed [sic] down on her bed ...Interventions completed by RN/Supervisor: Some faint red marks left in circular ring around neck. no respiratory distress...."


II. Based on review of documents, policies/procedures, and staff interviews, the facility failed to establish and maintain a safe environment for 25 of 25 adult male patient rooms, 15 of 15 adult female patient rooms, 12 of 12 child and adolescent patient rooms, including the common areas and hallways on nursing units that treated patients with a psychiatric diagnosis who may also be suicidal. The facility had 3 certified patient care areas: Adult Male ward R, Adult Female ward 21, and Children and Adolescent ward T. Observations on all three units showed the facility failed to:

- Maintain a safe environment by not removing bathroom stall brackets, concealing exposed plumbing, removing or replacing protruding exhaust fans, having doors that swing into the patient rooms, exposed door hinges, non-recessed door knobs, suspended ceiling with numerous anchor points above the tiles, vents and plastic grids in the suspended ceiling that when removed become a weapon, all easily accessible to patients.

-Identify, remove or replace faucets and shower heads that were not tamper-resistant or would not breakaway with application of an outside force and did not test for breakaway capacity. Cover or remove heater grills with sharp edges. Remove or replace wooden armed furniture with screws easily removed by patients.

Anchor points including, but not limited to; exposed plumbing, faucets, and pipes, door hinges, doorknobs, exhaust fans, bathroom stall brackets, conduit, electrical wires, and support beams above the ceiling tiles all provide an anchor point for a hanging device or noose that could and/or did for 3 patients (Patient #'s 1, 3, and 6) use in an attempt to commit suicide.

Access to sharp objects in the privacy of patient rooms provides opportunity for patients to injure themselves or others by cutting.

Additionally, ease of access to the suspended ceiling frame, tiles, grids, and vent fans provided weapons used by children and a storage area for contraband on all units.

Failure to remedy these safety hazards inhibits the facility's ability to maintain a safe environment for patients with a psychiatric diagnosis; which increases the risk for patient and staff harm, did result in patient harm, and could potentially result in a patient's death.

Inpatient census, at the time of the survey was:
- 18 on the Adult Men's ward R, 5 of 18 patients had a history of suicide attempts and 2 of the 5 attempted by hanging;
- 12 on the Adult Women's ward 21, 5 of 12 patients had a history of suicide attempts; and
- 8 on the Children and Adolescent ward T, 4 of 8 patients had a history of suicide attempts and 2 of the 4 attempted by hanging.

Findings include:

1. Observations on all 3 patient care wards 8/20/12 through 8/24/12 revealed the following:

-All bathroom stalls observed had gaps between the panels and the wall brackets that become an anchor point and was easily accessible to patients.

-All bathrooms observed revealed exposed plumbing on the toilets and urinals protruding from the wall, as well as, protruding hardwired fans, all creating anchor points, easily accessible to patients.

-All showers observed revealed exposed non-breakaway showerheads and faucets protruding from the wall creating an anchor point easily accessible to patients.

-Suspended ceilings in the patient care areas, bedrooms, and hallways had approximately A 10 to 12-inch distance between the hard ceiling and suspended ceiling. The ceiling tiles are easily accessible to patients by standing on a chair, the bed, window sill, or wardrobe. Observation above the ceiling tiles revealed multiple anchor points for hanging devices, easily accessible to patients, including, but not limited to, conduit, firebox junction, electrical wiring, metal support wires, support beams, and the ceiling frame itself; and some contraband found above the tiles. Record review showed patients on the Children and Adolescent ward T, on more than 1 occasion, had accessed the suspended ceiling, pulled the fan and/or grid out and used these items as weapons. Records also revealed children have also swung on the suspended ceiling frame kicking at staff in an attempt to keep them away.

-Patient bedroom doors opened inward enabling a patient to block themselves in and staff out of their room. Inward opening doors had exposed door hinges on the inside of the door, visible only to the patient inside the room, which protruded approximately 1-inch from the door, providing an anchor point for a hanging device. All doors observed had non-breakaway, non-recessed doorknobs that protruded from the inside and outside of the door and were 37 inches from the floor, providing an anchor point for a hanging device.

-Furniture on the Children and Adolescent ward T (18 of 21chairs with wooden arms) had screws that patients could and had removed.

2. Staff and patient interviews, throughout the investigation verified the facility staff was aware of the patient safety issues and reported incidence of their inability to maintain a saf

Based on review of policies/procedures, documents, and staff interview, the facility's Quality Assurance Committee failed to develop and implement a plan to correct multiple environmental hazards that created an unsafe environment for patients with a psychiatric diagnosis who may also be suicidal throughout. These hazards were present on all three certified patient care areas (Adult male ward R, Adult female ward 21, and the Children and Adolescent ward 21) of the certified hospital. Additionally, the facility's leadership failed to assure adequate resources to correct the environmental hazards.

The hospital safety committee identified multiple environmental hazards directly impacting the safety and well being of patients in the three certified patient care areas including the Children and Adolescent ward, Adult male ward, and the Adult female ward.

Failure to implement corrective action to eliminate the environmental hazards resulted in multiple opportunities for patients to harm themselves:

-A patient on the Adult male ward, attempting to hang himself from a bracket in a bathroom stall on 7/18/12. The safety issues with the bathroom stall brackets were identified for corrective action on an ongoing safety hazard flow sheet dated 2/15/11, at least 17 months before the incident.

-A patient on the Adult male ward, attempting to hang himself from a door knob on 7/16/12. The safety issues with the door knobs were identified as an environmental risk exposure on " Safety Survey notes " in the spring of 2012.

-A patient on the Children and Adolescent ward, attempted to hang them self from the frame of a suspended ceiling on 8/9/12. The facility identified the safety issues with the suspended ceiling and tiles in the Children and Adolescent ward as documented on the ward meeting notes dated 7/24/12.

The faculty's ongoing failure to correct environmental patient safety hazards continues to expose vulnerable patients with psychiatric diagnosis to multiple places in which to harm themselves or commit suicide.

Findings include:

1. Review of a memorandum from the facility Superintendent dated 9/14/89 revealed in part, "I have appointed a Safety Committee to manage an ongoing hospital-wide process to collect and evaluate information about hazards and safety practices. The information collected would be used to identify safety management issues...a risk-assessment program that evaluates the impact on patient care and safety of the buildings ...the safety officer works with appropriate staff to implement safety committee recommendations and to monitor the effectiveness of changes...the results of monitoring are reported to the safety committee. Identified safety management issues and summaries of safety committee activities are communicated at least quarterly to the governing body...and those responsible for other monitoring activities, including quality assurance."

2. Review of facility policy titled "Safety Management Plan", dated 12/15/10 revealed in part, "...Scope: To maintain and [sic] environment free of hazards and to minimize risk of harm to patients ...Introduction/Mission Statement: The Safety Management Program has its formal structure and charge as directed by the Superintendent (governing body) and has a management plan as set forth by regulation ...actual implementation of the Program rests with the Safety Officer and Safety Committee."

3. Review of Safety Committee Annual summary notes to the Governing Body dated 7/2/10 to 6/30/11 revealed the Safety Management Chapter failed to include environmental hazards on all 3 wards (Adult male ward R, Adult female ward 21, and the Children and Adolescent ward T).

4. During an interview on 8/23/12 the Administrator of Nursing (AON) acknowledged the Safety Management Chapter failed to include environmental hazards on all 3 wards (Adult male ward R, Adult female ward 21, and the Children and Adolescent ward T) as part of the quality improvement program. The AON said she had voiced safety issues that needed to be addressed in ward meetings and safety committee meetings on numerous occasions, but there were no attempts to resolve these issues, for the past year and a half.

5. Review of Quality Improvement (and Medical Records) Committee Meeting notes dated 1/19/12 revealed in part, "Safety Survey - Safety surveys were completed in July 2010 and again starting in December 2010 and lasting into February 2011. The wards ...were the primary focus of the surveys ...An emphasis is being made to conduct corrective action on areas of opportunity for self-harm on the wards."

6. During an interview on 8/22/12 at 9:50 PM, Staff A, Safety Officer said he uses a safety survey that includes a wide range of environmental observations throughout the facility. This includes patient care areas on the Adult male ward R, Adult female ward 21 and Children and Adolescent ward T. According to Staff A, there were multiple locations where the facility needed to remedy patient safety hazards including bathroom stalls with multiple anchor points. Staff A said an environmental multidisciplinary team was formed long before December 2011 to identify all environmental hazards on the adult male and female wards and the children's ward. Staff A said we've been working on this for the past 1-2 years.

7. Review of forms titled "Working Draft", dated 7/25/12, developed by Staff A outlined: the problem, the corrective action, implementation of corrective action, and the date the corrective action was completed. Review revealed in part a list of anchor points that could pose a potential for a patient to use to harm him/herself including, but not limited to, various elements regarding ceiling tiles, false ceiling grids and vents, smoke alarm cables, door knobs, door hinges, bathtub faucets, sink faucets, shower heads and faucets, conduit, exposed plumbing fixtures on the urinals and toilets, and toilet stall brackets. Staff A said the working draft forms identified areas on all three wards and date back two years. However, the facility had not implemented corrective action for any of these areas.

8. Quality Improvement (QI) Committee Meeting minutes from 12/15/11 to 3/17/11 and 1/19/12 to 7/9/12 lacked evidence that hospital leadership staff included these findings in their QI program and failed to formulate a plan to correct the identified environmental safety hazards. During an interview on 8/23/12 at 11:00 AM, the AON acknowledged the findings.