HospitalInspections.org

Based on observation, document review and staff interview, the facility failed, (a) to ensure the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured and (b) to comply with the FGI Guidelines as required by NY State Law - Part 405 Hospitals Minimum Standards.


Findings include:

During observations conducted on 4/26/23 at 10:00 AM and on 4/27/23 at 11:00 AM, the following were identified:

1) Eight (8) single patient bedrooms were converted to double bedded rooms, contrary to the design and plan of Kirby Forensic Psychiatric Center.
Those rooms included rooms # 633 a, 848 a, 1029 a, 1033 a, 729 a, 945 a, 1133 a, and room
945 a. The size of the converted rooms varied between 119 square feet to 126 square feet.

The size of all the converted rooms were not adequate to accommodate two (2) beds as per the facility design plan and per FGI Guidelines 2010 edition.
Also, the second beds that were added in each of the eight (8) rooms, were not bolted to the floor and could be lifted on top of a nightstand or the temporary provided storage unit and impose a looping risk.
Additionally, there were not enough storage space provided for patients who used the second beds.

FGI 2010, 2.5-2.2.2.2 - As required by NY State Law --- for Hospitals.
Space requirements (1) Patient rooms shall have a minimum clear floor area of 100 square feet (9.29 square meters) for single-bed rooms and 80 square feet (7.43 square meters) per bed for multiple-bed rooms.
2.5-2.2.2.8 Patient storage (1) Each patient shall have within his or her room a separate wardrobe, locker, or closet for storing personal effects.
(2) Shelves for folded garments shall be used instead of arrangements for hanging garments.
(3) Adequate storage shall be available for a daily change of clothes for seven days



2) The water temperature at the faucets of all the patient bathrooms were cold and varied between 53 F - 73 F.
The average water temperature required at the faucets shall range from 105 -120 F as per the FGI Guidelines - As required by NY State Law 1234 for Hospitals.
Water temperature is measured at the point of use or inlet to the equipment
Table 2.1-5 - Hot Water Use -General Hospital.


3) Review of the facility Complaint Log for 2022, revealed the presence of complaints about the cold temperature at different areas and patient rooms as follow:
a. It was too cold in rooms 218, 220 and 418 on 12/22/22.
b. Patient bedrooms cold in 6th floor 6A (Kirby Ward) on 12/14/22.
c. Room 540 is extremely cold on 12/23/22.
d. Freezing office temp in Kitchen Storehouse on 11/14/22.

The facility couldn't produce documented evidence that those complaints were addressed, or the issues were fixed in a timely manner.


These findings were identified in the presence of Staff B, Plant Superintendent, and were shared with Staff A, Executive Director, on 4/27/23 at 4:00 PM, who acknowledged the findings.

Based on observation, document review and staff interview, the facility failed to ensure the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

Review of the facility Complaint Log for 2022, revealed the presence of complaints about the cold temperature at different areas and patient rooms as follow:
a. It was too cold in rooms 218, 220 and 418 on 12/22/22.
b. Patient bedrooms cold in 6th floor 6A (Kirby Ward) on 12/14/22.
c. Room 540 is extremely cold on 12/23/22.
d. Freezing office temp in Kitchen Storehouse on 11/14/22.

The facility couldn't produce documented evidence that those complaints were addressed, or the issues were fixed in a timely manner.


During observations conducted on 4/26/23 at 10:00 AM and on 4/27/23 at 11:00 AM, the following were identified:

1) The cabinets for the fire extinguishers located at different areas on each floor of the facility, were observed to have gaps about ½ inch in diameter at the upper right-hand corner of each fire cabinet. The presence of gaps at the fire extinguisher cabinets is potential for looping hazard.
During an interview with Staff A, Executive Director and Staff B, Plant Superintendent on 4/27/23 at 11:00 AM, they indicated that those cabinets are in the corridors and that they are within sight of the nurse stations. The staff said the ligature risks are low.


2) On 4/26/23 at 12:00 PM, it was observed that the electric cord of the ice dispenser and the phone cord in the dining room 1119 A, were long and not secured, which posed looping risk.
Interview with Staff A, Executive Director, who was present during the observation, indicated that patients are never alone in the dining rooms and staff are always present with the patients in the dining rooms.

These findings were identified in the presence of Staff B, Plant Superintendent, and were shared with Staff A, Executive Director, on 4/27/23 at 4:00 PM, who acknowledged the findings.