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Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure patients received care in a safe setting :

The facility failed to identify and mitigate ligature risks in 8 of 8 patient bathrooms:

-there was a large opening between the toilet bowl and the wall. The opening was sufficient to loop a bedsheet through, tie it off, and use as a means for self-harm /asphyxiation.

Refer to Tag A-0144

Based on observation, interview, and record review, the facility failed to ensure care in a safe setting for 2 of 2 patients on suicide precautions {Patient ID # 5, # 6}.

The facility failed to identify and mitigate ligature risks observed in 8 of 8 patient bathrooms. This deficient practice poses significant risk all future patients assessed at risk for suicide.

Findings included :

TX00464449

Record review of a facility form titled "Suicide Risk in the Environment" showed multiple environmental suicide risks listed. One of the items listed was : "water faucets and toilet plumbing is covered." This was checked "yes" for assessments conducted in 2023: on March 3, April 4, May 5, June 2, July 3, August 3.
Record review of facility form titled "Environment of Care (EOC)," dated 01/01/2021, showed :

- Purpose: to reduce risk of injury or harm related to the environment of care;

- The Safety Committee meets six (6) times a year and inspects all areas to identify safety hazards.

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Observation on 08/23/2023 between 9:30 AM and 10: 15 AM showed two (2) clean uncluttered patient hallways . Female patients were admitted on one hall; males on the other. The hallways were divided by a nurses' station. During an interview with Staff-B, Director of Nurses (DON) she stated there were two (2) patients currently on suicide precautions ( Patients # 5, 6).

There was a total of 13 patient rooms; five (5) of these rooms had shared bathrooms ["Jack & Jill" set up]. Three (3) rooms had a private bathrooms. There were a toilet of eight (8) bathrooms.

Observation on 08/23/2023 at 11: 15 AM in an unoccupied patient room [#113 ] showed a toilet with a large opening between the toilet bowl and the wall. The opening was sufficient to loop a bedsheet through, tie it off, and use as a means for self-harm /asphyxiation.

Observation in the bathroom of an unoccupied patient room on 08/23/2023 at 12:45 PM with Staff -C, Director of Plant Operations, surveyor showed Staff-C how a bedsheet could looped through the opening between the toilet and the wall. The bedsheet was tied around the opening. The patient could sit on the toilet and tie the the other end of the bedsheet around his neck. The potential exists for the patient to purposely roll off the toilet onto the floor; and use the bedheet as a means of self-asphyxiation.

During an interview with Staff-C, Plant Operations Director, at the time of the observation, he said he had not considered this gaps as a ligature risk. Staff-C verified that all eight(8) patient bathrooms had toilets mounted this same way, with the large gap opening between the toilet and the wall.

On 8/23/2023 at 1:25 PM, surveyor requested Staff-A, the Administrator, accompany her to the bathroom of an unoccupied patient room. Surveyor described how a bedsheet could be looped through the opening between the toilet and the wall, and used by the patient as a means for self-asphyxiation. The Administrator acknowledged this was a ligature risk; and said all the gaps between the toilet and the wall would all be corrected.

Record review of the medical records of current Patients ID # 6, 5 showed:

-Patient ID # 6: 31 year old female, admitted on 08/22/2023 with severe anxiety and suicidal intent with a specific plan. Review of "suicide risk assessment" handwritten narrative " positive suicide ideation with plan to hang herself. Reports attempt last week by hanging. History of cutting one month ago. Current order for suicide precautions was verified with Staff-B, DON.

-Patient ID # 5: 53 year old male, admitted on 08/06/2023 with worsening depression and suicidal ideation with a plan to overdose on crack." Current order for suicide precautions was verified with Staff-B, DON.