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.

ST LUKES QUAKERTOWN HOSPITAL 3000 ST. LUKE'S DRIVE QUAKERTOWN, PA 18951 Jan. 25, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents, review of facility policy and procedures, observation of patient care units and interview with staff (EMP), it was determined the facility failed to ensure a safe setting was provided for all behavioral health patients.

Findings include:

Review on January 23, 2017, of "SLQH BHU [St Luke's Quakertown Hospital Behavioral Health Unit] Risk Assessment - 2015 revised 1/2016", revealed "... Shower fixtures ... need anti-ligature ... Day Room Closet doors in Day room with regular hinges. One in particular hidden behind other door and out of view of camera ..."

Review on January 23, 2017, of "Behavioral Health Risk Assessment Unit BHU" dated June 27, 2016, and November 14, 2016 revealed under the "patient rooms" section there was no mention of the need for anit-ligature hinges.


Review on January 23, 2017, of the facility's policies and procedures revealed there was no specific policy that specifically addressed the patients rights to receive care in a safe setting.


Observation of the facility's behavioral health unit on January 23, 2017, between 10:20 AM and 11:30 AM, revealed a 19 patient care adult general unit. Observation of Rooms 251, 252, 254, 255, 256, 258, 260, 261, and 263 revealed these rooms had non-safety door hinges on the entrance doors and bathroom doors which were considered to be a loopable possibility for patients who are suicidal. The entrance doors to these rooms also had a notched out area on the top of the doors which allowed for items to be more easily secured for a loopable possibility. Room 255 had a sink faucet that was a non-safety sink faucet that created a loopable possibility. The hallway doors also had non-safety door hinges. The door handle to leave the unit, on the left side, was approximately four feet off the ground and allowed for an item to be hung over it creating a loopable possibility.

The two closet doors in the Day Activity room had regular door handles and not anti-ligature door handles. This room also had two doors with regular door handles and non-safety anti-ligature hinges.

Patient Shower number one and number two had non-safety on/off shower valves that created a loopable possibility. These shower rooms also had non-safety door hinges on the entrance doors.

Interviews with EMP1 and EMP2 confirmed these observations during the tour.




Immediate Jeopardy was called on January 23, 2017, at 3:45 PM and abated at 6:45 PM after an acceptable Immediate Action Plan was received to eliminate immediate potential harm related to the unsafe physical environment.


Cross Reference:
482.41 Physical Environment
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of facility documents, review of facility policy and procedures, observation of patient care units and interview with staff (EMP), it was determined the facility failed to ensure a safe physical environment was provided for all behavioral health patients.

Findings include:

Review on January 23, 2017, of "SLQH BHU [St Luke's Quakertown Hospital Behavioral Health Unit] Risk Assessment - 2015 revised 1/2016", revealed "... Shower fixtures ... need anti-ligature ... Day Room Closet doors in Day room with regular hinges. One in particular hidden behind other door and out of view of camera ..."

Review on January 23, 2017, of "Behavioral Health Risk Assessment Unit BHU" dated June 27, 2016, and November 14, 2016 revealed under the "patient rooms" section there was no mention of the need for anit-ligature hinges.


Review on January 23, 2017, of the facility's policies and procedures revealed there was no specific policy that specifically addressed the patients rights to receive care in a safe physical environment.


Observation of the facility's behavioral health unit on January 23, 2017, between 10:20 AM and 11:30 AM, revealed a 19 patient care adult general unit. Observation of Rooms 251, 252, 254, 255, 256, 258, 260, 261, and 263 revealed these rooms had non-safety door hinges on the entrance doors and bathroom doors which were considered to be a loopable possibility for patients who are suicidal. The entrance doors to these rooms also had a notched out area on the top of the doors which allowed for items to be more easily secured for a loopable possibility. Room 255 had a sink faucet that was a non-safety sink faucet that created a loopable possibility. The hallway doors also had non-safety door hinges. The door handle to leave the unit, on the left side, was approximately four feet off the ground and allowed for an item to be hung over it creating a loopable possibility.

The two closet doors in the Day Activity room had regular door handles and not anti-ligature door handles. This room also had two doors with regular door handles and non-safety anti-ligature hinges.

Patient Shower number one and number two had non-safety on/off shower valves that created a loopable possibility. These shower rooms also had non-safety door hinges on the entrance doors.

Interview with EMP1 and EMP2 confirmed these observations during the tour.

Immediate Jeopardy was called on January 23, 2017, at 3:45 PM and abated at 6:45 PM after an acceptable Immediate Action Plan was received to eliminate immediate potential harm related to the unsafe physical environment and the number of patients on Suicide Precautions.



Cross Reference:
482.13 (c) (2) - Patient Rights - Patient has the right to receive care in safe setting