The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HARTFORD HOSPITAL 80 SEYMOUR STREET HARTFORD, CT 06102 April 28, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
The hospital failed to ensure and/or maintain a safe environment for a patient who had a recent history of suicide attempts including self-harm and self-injurious gestures, failed to provide individual and specific interventions in the Interdisciplinary Treatment Plan (ITP) to address suicidality, self-harm and self-injurious gestures, failed to provide adequate nursing supervision to ensure safety, failed to ensure the patient did not have access to a plastic knife that was used to cut a ceiling tile to aid in a suicide attempt, and failed to ensure that the patient was cared for in a safe environment free from access to ligature points found above the spline ceiling that resulted in harm when a patient made a suicide attempt by hanging using a sheet to attach to an area above the ceiling tiles which resulted in a finding of Immediate Jeopardy.

Please see A 144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



1. Based on review of clinical records, review of hospital policies, observations and staff interviews for 1 of 11 patients (P#101) who were at risk for suicide, the hospital failed to ensure the patient was cared for in a safe environment, free from access to ligature points leading to a suicide attempt by hanging that caused injury to the patient, which resulted in a finding of Immediate Jeopardy (IJ). The findings include:
a. Patient #101 was admitted on [DATE] with diagnoses that included unspecified depressive disorder, oppositional defiant disorder (ODD) and impulse control disorder. Factors leading to hospitalization according to the admission database included superficial cutting of extremities, hiding sharps, attempt to burn self with a lighter and a recent attempt at overdose which required an admission to another Psychiatric facility. The admission database indicated P#101 was alert, oriented coherent and exhibited compromised judgment. On 4/11/16 an admission suicide risk assessment indicated P#101 denied suicidal/homicidal ideation. A suicide risk level was identified as low and P#101 was placed on standard monitoring checks every 15 minutes.
A review of the clinical record identified that the patients Individualized Treatment Plan (ITP) as developed on 4/11/16. An active problem list dated 4/11/16 indicated P#101 had a history of superficial cutting, recent attempt at overdose, the tendency to hide sharps and an attempt to burn him/herself with a lighter. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included to observe P#101's behavior and remove potentially dangerous objects. However, the ITP failed to identify specific interventions regarding the patient ' s safety as related to the patient ' s history of cutting, overdose, self-burning, hiding of sharp objects and the threat of hanging.

The ITP dated 4/11/16 identified P#101's suicide risk level was low. A suicide risk assessment completed on 4/13/16 indicated P#101 was at a moderate risk level for suicide due to his/her history of suicidal and oppositional behaviors. According to a progress note dated 4/14/16, P#101 placed a bed sheet over the bathroom door activating the door alarm. P#101 denied having intent to self-harm and stated that he/she was attempting to make a fort. P#101 was evaluated by psychiatry and a subsequent suicide assessment dated [DATE] indicated P#101's suicide risk level remained at moderate risk. The suicide risk assessment indicated the bathroom door was to be locked and bathroom use was to be with an escort. However, the ITP was not updated to include the behavior of placing a sheet over a door. Documentation continued to indicate P#101 remained at a low risk for suicide instead of at moderate risk as identified by the psychiatrist on 4/15/16.

A review of written documentation (kardex) used by Psychiatric Technicians to provide clear written direction for care of the patients identified P#101's name, demographic information, identifying information, diet, medications and that P#101 was at risk for suicide. However the documentation did not reflect any specific directions regarding interventions relative to P#101's prior suicide history. In addition the Psychiatric Technicians kardex failed to identify specific interventions that addressed P#101's history of cutting, overdose, self-burning, hiding of sharp objects, threat of hanging and/or any treatment plan goals and/or interventions specific to the safety needs of P#101.

Subsequently, on 4/16/16 at approximately 9:05 PM, P#101 used a plastic knife, taken from the dining area during dinner, climbed on a desk and cut a hole in the spline ceiling tile in his/her room large enough to fit his/her hand into. P#101 proceeded to place a bedsheet over exposed pipes and attempted to hang him/herself. According to P#101 he/she remained suspended for a short period of time before the knot in the sheet became undone and he/she fell to the floor striking his/her face, hip and thigh. P#101 was transferred to a local hospital for evaluation and treatment. According to Emergency Department (ED) documentation the patient exhibited periorbital soft tissue swelling/hematoma and a 1 centimeter laceration and tenderness to his/her right hip caused during the fall. In addition there were noted ligature marks around his/her neck. A CT scan was negative for head injury. According to the ED documentation the facility staff had reported that P#101 was wearing a choker necklace during the hanging attempt. Additionally, a photograph on the Psychiatric Technicians kardex, dated 4/11/16 identifies P#101 wearing a dark colored choker necklace resting at the base of his/her neck. On 4/17/16 at 2:00 AM P#101 returned to the facility and was placed on constant observation.
A hospital guideline for sharps and potentially dangerous items identified that jewelry was optional per patient. The clinical record lacked an assessment of P#101's safety needs in relation to a choker necklace.
A progress note dated 4/16/16 at 11:10 PM indicated P#101 had used a plastic knife that had been taken out of the dining room during dinner to cut a hole large enough to fit his/her hand in and proceeded to attempted to hang his/her self with a bedsheet from the hole in the ceiling. The progress note further indicated that while P#101 was transferred to the ED, staff found several pieces of metal hidden in his/her pillowcase that P#101 had taken from the damaged ceiling.

During an interview with Registered Nurse (RN) #100 on 4/27/16 at 2:00 PM, RN#100 indicated when the incident occurred he/she immediately responded to P#101's room. Upon arrival he/she noted several broken pieces of ceiling tile on the desk that P#101 had jumped from in an attempt to hang him/her self. Additionally RN#100 indicated he/she observed a plastic knife on the desk. Upon surveyor inquiry RN#100 indicated Psychiatric Technicians do not check every patient's tray upon completion of meals to ensure all eating utensils are returned. During an interview with Psychiatric Technician #100 on 4/27/16 at 4:45 PM he/she additionally indicated that the staff do not check every tray to ensure eating utensils are returned after meals. During dining observation and interview with Psychiatric Technician #101 on 4/27/16 at 12:10 PM he/she indicated some staff do check to ensure eating utensils are on the meal trays however the environmental check sheet failed to identify the staff member(s) responsible for this task.
According to the facility Regulation of Sharps and Potentially Dangerous Items Policy: Potentially dangerous items are those objects in the possession of the patient that could reasonably be used to inflict harm on self or others. Staff supervise patient use of potentially dangerous items. All sharps will be counted and signed out at the beginning of a group and counted and signed back in again at the end of the activity.
According to the facility Patient Observation Checks and Level of Care Policy: Staff performing 15 minute observation checks are responsible for scanning the environment which is important to promoting a safe environment. Report any areas of concern to the charge RN.



2. Based on staff interview and review of hospital documentation for 1 patient (P#101), the hospital failed to activate an emergency response in accordance with facility policy when a patient sustained injuries in a suicide attempt. The findings include:
Interviews with RN#100 and RN#101 on 4/28/16 identified that hospital staff did not call a rapid response following Patient #101' s failed suicide attempt by hanging despite visible injury to the patient's body. Instead, hospital staff called an ambulance company directly. Review of the ambulance run sheet (# ) indicated that the call for the ambulance was received at 9:37 PM, the ambulance arrived at the hospital at 10:02 PM, and P#101 was transported to another hospital's emergency department arriving at 10:15PM (38 minutes from the time of call).


Review of policy # C-6.6, identified that in an emergency, staff were required to dial
2-11-11 which connected the caller to the Public Safety Dispatch Center.

3. Based on interviews with staff and review of documentation, the hospital failed to conduct a comprehensive investigation and/or comprehensive review of the unit environment when a patient (P#101) attempted suicide. Review of the incident with the Director of Nursing for Behavioral Health on 4/27/16 at 12:30 PM identified that specific details regarding P#101's suicide attempt were not documented in a formal investigation, did not include staff and patient interviews, did not include how or when the patient gained access to a sharp object (plastic knife), did not include the patient's behavior prior to the incident, and did not include a risk assessment of the environment throughout the unit as it pertained to the safety of other patients on the unit.

4. Based on observations, staff interviews, and review of hospital documentation, the hospital failed to ensure that the physical environment on the psychiatric unit was maintained in a safe manner. During tour of the facility on 04/28/16 at 08:30AM and times throughout the day, the Surveyor along with Director of Engineering, Manager of Fire Safety (Fire Marshal) and the Carpentry Shop Foreman observed the following:

a. The concealed spline ceiling tile system throughout the twelve rooms (12) utilized for adolescent psychiatric patients, eleven (11) had a spline ceiling system that was not 100% intact. The 11 patient rooms had ceiling tiles that were not affixed to the spline system, tiles that were broken, cracked, hanging, and/or missing corners.
b. The grid used to support the ceiling system could support the weight of an adult male as tested by the surveyor on the day of survey (4/28/16), and above the spline ceiling tiles in the plenum space there were multiple pipes and supports that could be used a ligature point.

c. Documentation review indicated that Patient #101 was in room 205 and attempted suicide on 04/16/16 at approximately 9:00 PM by cutting a hole in the spline ceiling gaining access to the plenum space and affixing a bed sheet to a ligature point within that space. The facility initiated a green slip (request for repair) on 04/17/16 for the repair of the ceiling. The work order was issued on 04/18/16 and time stamped at 3:05 PM. Interview of the Director of Engineering identified that the facility process of issuing work orders provides erroneous time stamps as they are not printed or closed till the end of the day even if issued in the morning. Patient #101 was returned to the same room of the suicide attempt before the ceiling was repaired as the patient was on constant observation.

d. Documentation was not available on the day of survey to indicate that the facility was testing the door pressure alarms semiannually as required by facility policy reviewed 06/2015 last revised 03/12/15.
e. A tour and observations of the other patient care units of the Donnelly building identified the use of the spline ceiling tile system. On the 1 north and 1 South Cares unit observations identified that spline ceiling tiles were not affixed to the spline system, tiles were broken and cracked, hanging, and missing corners. In addition, room 143 had a non-institutional sprinkler head.
f. Soap dispenser in all patient bathrooms were noted to be constructed of a material (plastic) that had the potential to harm residents if broken or damaged and not suitable for institutional use.

g. General lighting in patient rooms was noted to overhead fluorescent tube lighting protected only by plastic lens and did not include designed or safeguarded tamper resistant for institutional use.

h. The facility environmental rounds conducted on 9/22/15 and 2/3/16 were reviewed on the day of survey (4/28/16) and indicated that all ceilings were intact. The document did not indication if patient rooms were entered and checked.

i. The comfort room had non institutional door hinges and plastic wall guards that were broken with jagged sharp edges.
j. The seclusion room had wall damage and ceiling damage.
VIOLATION: NURSING SERVICES Tag No: A0385
The Condition of Nursing Services has not been met. Based on review of medical records, review of facility policies and interviews, for 9 of 11 patients (P#101, #102, #103, #104 #106, #107, #108, #110 and #111), the hospital failed to update the individualized treatment plans (ITP) relative to suicide risk level and/or identify individualized interventions in the (ITP) and/or identify individualized nursing care needs on the daily assignments for Psychiatric Technicians in order to provide, clear written direction for care of the patients.

Please see A396
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records, review of the facility policies and interviews for 9 of 11 patients (P#101, #102, #103, #104 #106, #107, #108, #110 and #111), the facility failed to update the individualized treatment plan (ITP) relative to suicide risk level and/or identify individualized interventions in the (ITP) and/or identify individualized nursing care needs on the daily assignments for Psychiatric Technicians in order to provide, clear written direction for care of the patients. The findings include:

1. Patient #101 was admitted on [DATE] with diagnoses that included unspecified depressive disorder, oppositional defiant disorder (ODD) and impulse control disorder. Factors leading to hospitalization according to the admission database included superficial cutting of extremities, hiding sharps, attempt to burn self with a lighter and a recent attempt at overdose which required an admission to another Psychiatric facility. The admission database indicated P#101 was alert, oriented coherent and exhibited compromised judgment. On 4/11/16 an admission suicide risk assessment indicated P#101 denied suicidal/homicidal ideation. Suicide risk level was identified as low and P#101 was placed on monitoring checks every 15 minutes.
A review of the clinical record identified that the patients individualized Treatment Plan (ITP) was developed on 4/11/16. An active problem list dated 4/11/16 indicated P#101 had a history of superficial cutting, recent attempt at overdose, an attempt to burn him/herself with a lighter and the tendency to hide sharps. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#101's behavior and remove potentially dangerous objects however the ITP failed to identify specific interventions regarding the patients safety as related to the patients history of cutting, overdose, self-burning, hiding of sharp objects and the threat of hanging. The ITP dated 4/11/16 identified P#101's suicide risk level was low. A suicide risk assessment completed on 4/13/16 indicated P#101 was at a moderate risk level for suicide due to his/her history of suicidal and oppositional behaviors. According to a progress note dated 4/14/16 P#101 placed a bed sheet over the bathroom door activating the door alarm. P#101 denied having intent to self-harm and stated that he/she was attempting to make a fort. P#101 was evaluated by psychiatry. A subsequent suicide assessment dated [DATE] indicated P#101's suicide risk level remained at moderate risk. The suicide risk assessment indicated the bathroom door was to be locked and bathroom use was to be with an escort however the ITP was not updated pertaining to the incident and continued to indicate P#101 remained at a low risk for suicide.
A review of the Psychiatric Technician kardex used to provide, clear written direction for the care of the patient identified P#101's name, demographic information, identifying information, diet, medications and that P#101 was at risk for suicide however the documentation did not reflect any specific directions regarding interventions relative to P#101's prior suicide history and/or any treatment plan goals and/or interventions specific to the needs of P#101.
Subsequently, on 4/16/16 at approximately 9:05 PM P#101 had apparently used a plastic knife, taken from the dining area during dinner, climbed on a desk and cut a hole in the ceiling tile of his/her room large enough to fit his/her hand into. P#101 proceeded to throw a bedsheet over pipes exposed when he/she broke the tile and attempted to hang him/herself. According to P#101 he/she remained suspended for a short period of time before the knot in the sheet became undone and he/she fell to the floor striking his/her face, hip and thigh. P#101 was transferred to a local hospital for evaluation and treatment. According to Emergency Department (ED) documentation the patient exhibited periorbital soft tissue swelling/hematoma and a 1 centimeter laceration and tenderness to his/her right hip caused during the fall. In addition there were noted ligature marks around his/her neck. According to the ED documentation the facility staff had reported that P#101 was wearing a choker necklace during the hanging attempt. Additionally a photograph on the Psychiatric Technicians kardex, dated 4/11/16 exhibits P#101 wearing a dark colored choker necklace resting at the base of his/her neck. A CT scan was negative for head injury. On 4/17/16 at 2:00 AM P#101 returned to the facility and was placed on constant observation.

2. Patient #102 was admitted on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD) with dissociative features. In addition P#102 had a prior history of cutting him/her self. Factors leading to hospitalization included hallucinations and positive suicidal/homicidal ideations. On 4/11/16 a suicide risk assessment indicated P#102's suicide risk level was identified as low and P#102 was placed on monitoring checks every 15 minutes.
A review of the clinical record identified that the patients ITP was developed on 4/11/16. A problem of suicidal/homicidal ideation was identified. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#102's behavior and remove potentially dangerous objects however the ITP and/or Psychiatric Technician kardex failed to identify P#102's past psychiatric history and/or specific interventions regarding the patients safety as related to the patients history of cutting.

3. Patient #103 was admitted on [DATE] with diagnoses that included asthma and a recent history of depression. Factors leading to hospitalization according to the admission database included recent history of cutting his/her extremities and a plan to jump off a bridge.
A review of the clinical record identified that the patients ITP was developed on 4/14/16. A problem of low suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#103's behavior and remove potentially dangerous objects however the ITP failed to identify specific interventions regarding the patients safety as related to the patients history of cutting and/or plan to jump off a bridge. On 4/18/16 a suicide risk assessment indicated P#103 was found with contraband for cutting and fresh cuts were noted on P#103's right arm. P#103's suicide risk was upgraded to moderate risk and additional interventions included bathroom supervision and the removal of clothing and bedsheets. Review of the ITP and/or Psychiatric Technician kardex failed to identify that P#103's risk level had changed from low to moderate risk and failed to identify the new interventions put in place. In addition the kardex failed to identify specific behaviors and/or interventions related to P#103's history of cutting.

4. Patient #104 was admitted on [DATE] with diagnoses that included obsessive compulsive disorder, auditory and visual hallucinations. Factors leading to hospitalization according to a psychiatric emergency assessment dated [DATE] indicated P#104 had expressed suicidal ideation with a plan to jump off a highway overpass or drink a bottle of bleach. Documentation indicated P#104 had a history of an overdose attempt 8 months ago and a history of fire setting.
A review of the clinical record identified that the patients ITP was developed on 4/22/16. A problem of suicidal/homicidal ideation was identified. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#104's behavior and remove potentially dangerous objects however the ITP and/or Psychiatric Technician kardex failed to identify specific interventions regarding the patients safety as related to the patients history of cutting and/or fire-setting. On 4/25/16 a suicide risk assessment indicated P#104 suicide risk level was identified as moderate. Review of the ITP failed to identify that P#104's risk level had changed to moderate.

5. Patient #106 was admitted on [DATE] with diagnoses that included PTSD and depression. Factors leading to hospitalization according to the active problem list dated 4/15/16 included self-injurious behaviors such as cutting, overdose self-induced weight loss and 7 previous suicide attempts. On 4/18/19 a suicide risk assessment indicated P#106 suicide risk level was identified as low and P#106 was placed on monitoring checks every 15 minutes.
A review of the clinical record identified that the patients ITP was developed on 4/15/16. A problem of suicide risk was identified however the ITP failed to identify the suicide risk level and Interventions including to observe P#106's behavior and remove potentially dangerous objects. In addition the ITP failed to identify specific interventions regarding the patient's safety as related to cutting, overdose and nutrition.

6. Patient #107 was admitted on [DATE] with diagnoses that included schizoaffective disorder. Factors leading to hospitalization according to the active problem list dated 4/21/16 included self-injurious behaviors such as overdose, aggression, paranoia and the threat of cutting his/her wrists. A review of the clinical record identified that the patients ITP was developed on 4/21/16. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#107's behavior and remove potentially dangerous objects however the ITP and or Psychiatric Technician kardex failed to identify specific interventions regarding the patients safety as related to the patients history of overdose, violent behavior and potential for cutting. Review of the ITP failed to identify the behavioral observations identified on admission such as paranoia and rage. On 4/22/16 a suicide risk assessment indicated P#107 suicide risk level was identified as low and P#107 was placed on monitoring checks every 15 minutes.

7. Patient #108 was admitted on [DATE] with diagnoses that included borderline personality disorder. Factors leading to hospitalization according to the active problem list dated 4/17/16 included history of cutting, burning him/herself, plan to hang self and hallucinations with suicidal/homicidal content.
A review of the clinical record identified that the patients ITP was developed on 4/17/16. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#108's behavior and remove potentially dangerous objects however the ITP and/or Psychiatric Technician kardex failed to identify specific interventions regarding the patients safety as related to the patients history of cutting, burning him/her self. On 4/18/16 a suicide risk assessment indicated P#108 suicide risk level was identified as low and P#108 was placed on monitoring checks every 15 minutes.

8. Patient #110 was admitted on [DATE] with diagnoses that included bipolar disorder and anxiety. Factors leading to hospitalization according to the active problem list dated 3/27/16 included a plan to stab him/her self and/or thoughts of overdose and/or hang him/her self. On 3/27/16 an admission suicide risk assessment indicated P#110's suicide risk level was identified as moderate and P#110 was placed on monitoring checks every 15 minutes. Although the suicide risk assessment indicated P#110 was assessed as a moderated risk for suicide P#110's ITP dated 3/27/16 identified a problem of suicide risk the ITP identified P#110 as low risk for suicide. Long term goals indicated the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#110's behavior and remove potentially dangerous objects however the ITP and/or Psychiatric Technician kardex failed to identify specific interventions regarding the patients safety as related to the patients history of threatening overdose, hanging or stabbing him/her self.

9. Patient #111 was admitted on [DATE] with diagnoses that included bipolar disorder, obsessive compulsive disorder, PTSD, depression and anxiety. Factors leading to hospitalization according to the active problem list dated 4/15/16 included history of cutting and burning him/her self with a lighter.
A review of the clinical record identified that the patients ITP was developed on 4/15/16. A problem of suicide risk was identified with long term goals indicating the patient would not harm him/herself and/or attempt suicide during hospitalization . Interventions included observe P#111's behavior and remove potentially dangerous objects however the ITP and/or Psychiatric Technician kardex failed to identify specific interventions regarding the patients safety as related to the patients history of cutting and burning him/her self . On 4/18/16 a suicide risk assessment indicated P#111's suicide risk level was identified as low.

During a review of the medical records of P#101, #102, #103, #104 #106, #107, #108, #110 and #111 on 4/28/16 at 2:20 PM with the Director of the Inpatient Child/Adolescent Unit he/she indicated the individualized treatment plan should identify specific behaviors related to the patients history and any specific interventions to address those behaviors. In addition the Director of the Inpatient Child/Adolescent Unit indicated all patients have a Safe-T risk assessment on admission, at the treatment plan meetings, upon discharge and with any change in behavior to assess for suicide risk. The patient is classified as high, moderate or low. The patient may be high or moderate in the ED but upon admission to the hospital they may be assessed as low because they are here in the hospital and express no thoughts of suicide. If there is any change in behavior the patient is reassessed and the ITP updated as appropriate.
Facility Interdisciplinary Treatment Plan policy indicated that the treatment plan shall include specific treatment modalities.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on tour, review of policies, observations made on 04/28/16, staff interviews and review of hospital documentation the hospital failed to ensure that the Condition of Physical Environment was met failed by failing to ensure that the physical environment on the psychiatric unit was maintained in a safe manner.


See A701
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, staff interviews, and review of hospital documentation, the hospital failed to ensure that the physical environment on the psychiatric unit was maintained in a safe manner. During tour of the facility on 04/28/16 at 08:30AM and times throughout the day, the Surveyor along with Director of Engineering, Manager of Fire Safety (Fire Marshal) and the Carpentry Shop Foreman observed the following:

a. The concealed spline ceiling tile system throughout the twelve rooms (12) utilized for adolescent psychiatric patients, eleven (11) had a spline ceiling system that was not 100% intact. The 11 patient rooms had ceiling tiles that were not affixed to the spline system, tiles that were broken, cracked, hanging, and/or missing corners.
b. The grid used to support the ceiling system could support the weight of an adult male as tested by the surveyor on the day of survey (4/28/16), and above the spline ceiling tiles in the plenum space there were multiple pipes and supports that could be used a ligature point.

c. Documentation review indicated that Patient #101 was in room 205 and attempted suicide on 04/16/16 at approximately 9:00 PM by cutting a hole in the spline ceiling gaining access to the plenum space and affixing a bed sheet to a ligature point within that space. The facility initiated a green slip (request for repair) on 04/17/16 for the repair of the ceiling. The work order was issued on 04/18/16 and time stamped at 3:05 PM. Interview of the Director of Engineering identified that the facility process of issuing work orders provides erroneous time stamps as they are not printed or closed till the end of the day even if issued in the morning. Patient #101 was returned to the same room of the suicide attempt before the ceiling was repaired as the patient was on constant observation.

d. Documentation was not available on the day of survey to indicate that the facility was testing the door pressure alarms semiannually as required by facility policy reviewed 06/2015 last revised 03/12/15.
e. A tour and observations of the other patient care units of the Donnelly building identified the use of the spline ceiling tile system. On the 1 north and 1 South Cares unit observations identified that spline ceiling tiles were not affixed to the spline system, tiles were broken and cracked, hanging, and missing corners. In addition, room 143 had a non-institutional sprinkler head.
f. Soap dispenser in all patient bathrooms were noted to be constructed of a material (plastic) that had the potential to harm residents if broken or damaged and not suitable for institutional use.

g. General lighting in patient rooms was noted to overhead fluorescent tube lighting protected only by plastic lens and did not include designed or safeguarded tamper resistant for institutional use.

h. The facility environmental rounds conducted on 9/22/15 and 2/3/16 were reviewed on the day of survey (4/28/16) and indicated that all ceilings were intact. The document did not indicate if patient rooms were entered and checked.
i. The comfort room had non institutional door hinges and plastic wall guards that were broken with jagged sharp edges.
j. The seclusion room had wall damage and ceiling damage.