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.

HOPEBRIDGE HOSPITAL 5556 GASMER DRIVE HOUSTON, TX March 8, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, and record review, on March 7-8, 2017, the governing body failed to provide effective oversight to ensure that patients are provided treatment in a safe environment.


1. The facility did not ensure the rights of each patient to receive treatment in a safe setting as evidenced by multiple ligature risks.

2. The facility did not ensure the rights of each patient to receive treatment that meets their needs as evidenced by incomplete or inaccurate suicide self-harm assessments conducted by the nursing staff.

3. The facility was not constructed and maintained to guarantee the safety and well-being of each patient as evidenced by the presence of multiple ligature risks.


The identified practices present a likelihood of Immediate Jeopardy to the 33 current patients and all potential patients with behavioral problems on the adult and adolescent units.


Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive treatment in a safe setting as evidenced by all patients placed on units with multiple ligature risks present that were easily accessible for self-harm. This poses a risk for current and potential patients with behavioral problems on the adult and adolescent units. Refer to 482.13(c)(2) - [A-0144].


Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive treatment that meets their needs as evidenced by incomplete or inaccurate suicide self-harm assessments. This poses a risk for current and potential patients with behavioral problems on the adult and adolescent units. Refer to 482.13(c)(3) - [A-0142].


Based on observation, interview, and record review, the facility failed to construct and maintain an environment that guaranteed the safety and well-being of each patient as evidenced by multiple ligature risks in the patient care areas. This poses a risk for current and potential patients with behavioral problems on the adult and adolescent units. Refer to 482.41(a) - [A-0701].
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation, interview, and record review, the facility failed to ensure the rights of each patient to receive treatment to meet their needs as evidenced by incomplete suicide self-harm assessments or inaccuratesuicide self-harm assessment in 3 of 6 patients (patient #1, #6, and patient #11).


Findings included:


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1300, she stated that the previous RN Educator, Personnel #57, did not properly in-service the staff on the Suicide Self-Harm Admission and Discharge Assessment tool.


Review of the Plan for Patient Safety Regarding Ligature Risk and Suicide Risk formulated by Personnel #52 (CCO), dated March 3, 2017, at 1638, revealed: "All unit staff currently working have been have (sic) retrained on the use of the suicide tool at 100% ... The nursing suicide tools will be added to the 24-hour chart checks and supervisors rounds and audited daily by the CCO."


Further, review of the 15 Suicide Self-Harm Admission and Discharge Assessment tools listed above (February and March of 2017) revealed five admissions and one discharge for a period ending March 3, 2017. Three (50%) of the Suicide Self-Harm Admission and Discharge Assessment tools for patient #1, #6, and patient #11 were not completed or were completed incorrectly by various RNs. The patient's behaviors were not identified on the assessment tool.


Review of the Suicide Self-Harm Admission and Discharge Assessment for Patient #1 dated March 7, 2017, (no time) had no signature by the RN. The first question, "Is the current admission precipitated by a suicide attempt?" was not answered. The total score was inaccurate.


Review of the Suicide Self-Harm Admission and Discharge Assessment by Personnel #61 (RN) for Patient #6 dated March 5, 2017, revealed no symptoms were circled and the score was inaccurate.


Review of the Suicide Self-Harm Admission and Discharge Assessment by Personnel #60 (RN) for Patient #11 dated March 5, 2017, at 2408 revealed "3-4 symptoms" circled. Seven symptoms were identified in the RN's note. No symptoms were circled as instructed in the directions. The nurse had also scored the tool as a 7 and a 6.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review, the facility failed to promote and protect the rights of each patient to receive treatment in a safe setting as evidenced by 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) were placed on units with multiple ligature risks present that were easily accessible. These five patients were on suicidal precautions. This poses a risk for current and potential patients with suicidal ideation on the adult and adolescent units.


Findings included:


In an interview with Personnel #51 (CEO) on March 7, 2017 at 0900, he stated:

1. The facility only admitted psychiatric patients onto the adult and adolescent units.

2. From a CMS perspective, HopeBridge Hospital is a general medical surgical hospital transitioning to a free-standing psychiatric hospital.

3. From a State perspective, HopeBridge Hospital is licensed as a special hospital that has chosen to be exclusively psychiatric.


Patient Bedrooms.

Record review of Unit 1 Patient Census dated March 8, 2017, at 1200, revealed 22 patients (patients #2 through #23) occupying 18 bedrooms (rooms numbered 101, 102, 103, 104, 105, 106, 107, 108, 112, 114, 119, 120, 121, 122, 123, 124, 125, and 126). Two patients were identified as being on suicide precautions: Patient #20 and Patient #2.


Record review of the medical record for Patient #20:

1. Registration Record revealed admitted /time of March 7, 2017, at 1950.

2. Initial Psychiatric Evaluation by Personnel #64 (MD) dated March 8, 2017, at 1630, revealed, "Worsening of psychotic and depressive symptoms ... increase auditory hallucinations 'to hurt myself' ... active suicidal ideation."

3. Psychiatric Admission Orders by Personnel #64 (MD) dated March 7, 2017, at 1812, revealed suicide precautions.


Record review of the medical record for Patient #2:

1. Registration Record revealed admitted /time of February 28, 2017, at 1731.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 1, 2017, at 1235, revealed, "Suicidal thoughts ... auditory hallucinations ... worsening psychosis and suicidal ideation [with] intent ... schizophrenia, paranoid type."

3. Physician's Admitting Orders by Personnel #63 (MD) dated February 28, 2017, at 2224, revealed suicide precautions.

4. Physician Orders by Personnel #64 (MD) dated March 1-8, 2017, at various times revealed renewal of suicide precautions.


Record review of Unit 2 Patient Census dated March 8, 2017, revealed 11 patients (patients #24 through #34) occupying 10 bedrooms (rooms numbered 205, 206, 207, 208, 219, 220, 221, 222, 223, and 224). Three patients were on suicide precautions: Patient #34, #32, and Patient #27.


Record review of the medical record for Patient #34:

1. Registration Record revealed admitted /time of March 8, 2017, at 0043.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 8, 2017, at 2333, revealed, "Depression ... with suicidality ... took an overdose ... remains suicidal ... with persistent suicidal urges and plans."

3. Admission Orders by Personnel #62 (MD) dated March 7, 2017, revealed suicide precautions.

4. Physician Orders by Personnel #62 (MD) dated March 8, 2017, revealed renewal of suicide precautions


Record review of the medical record for Patient #32:

1. Registration Record revealed admitted /time of March 8, 2017, at 0200.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 8, 2017, at 0704, revealed, "Depression ... with suicidality ... plans to drown ... or hang [herself] ... hallucinating."

3. Physician Orders by Personnel #62 (MD) dated March 8, 2017, revealed suicide precautions.


Record review of the medical record for Patient #27:

1. Registration Record revealed admitted /time of March 6, 2017, at 2225.

2. Physician's Admitting Orders by Personnel #63 (MD) dated March 6, 2017, at 2232, revealed suicide precautions.

3. Initial Psychiatric Evaluation by Personnel #54 (MD) dated March 7, 2017, at 0700, revealed, "Questionably suicidal ideation ... hallucinations."

4. Physician Orders by Personnel #54 (MD) dated March 8, 2017, at 0900, revealed renewal of suicide precautions.


Observation of Unit 1 on March 8, 2017, at 1200, revealed 24 patient bedrooms: 18 bedrooms were occupied by patients (rooms numbered 101, 102, 103, 104, 105, 106, 107, 108, 112, 114, 119, 120, 121, 122, 123, 124, 125, and 126) and six were empty (rooms numbered 111, 113, 115, 116, 117, and 118). All 24 bedrooms had the following ligature risks: push-pull door handles and architectural grade butt hinges on the doors opening into the bedrooms from the hallway, faucets, and air vents.


Observation of Unit 2 on March 8, 2017, at 1230, revealed 18 patient bedrooms: ten bedrooms were occupied by patients (rooms numbered 205, 206, 207, 208, 219, 220, 221, 222, 223, and 224) and eight were empty (rooms numbered 209, 210, 211, 212, 214, 216, 217, and 218). All 18 bedrooms had the following ligature risks: push-pull door handles and architectural grade butt hinges on the doors opening into the bedrooms from the hallway, faucets, and air vents.


During observations on Unit 1 on March 8, 2017, at 1200, Personnel #52 (CCO) and Personnel #55 (MHT) were present. A sheet was successfully tied around the faucet located in bedroom #120. The knot held firm when the sheet was pulled forcibly to both sides and the front of the sink. Next, a knot was tied in one corner of the sheet. The sheet was wedged across the top of the highest door hinge. The door was then shut with the knot on the outside of the door and the remainder of the sheet inside the door. The knot held firm when the sheet was pulled forcibly. Push-pull door handles were on the door. A metal air vent was in the room. Both provided ligature risks.


In interviews with Personnel #52 (CCO) and Personnel #55 (MHT) on March 8, 2017, at 1200, both stated that the faucets found in the patient's rooms were a ligature risk. Personnel #52 (CCO) further stated the door hinges and handles found on all of the bedroom doors and metal air vents in all of the patient rooms were ligature risks.


In an interview with Personnel #52 (CCO) on March 7, 2017, at 0900, she stated:

1. The doors to the patient's rooms do not lock.

2. Patients are not allowed to go into unoccupied bedrooms.

3. A system had been put into place so that tape is placed across the door of unoccupied rooms and then dated, timed, and initialed by staff.


Review of the Plan for Patient Safety Regarding Ligature Risk and Suicide Risk by Personnel #52 (CCO), dated March 3, 2017, at 1638, revealed a plan to put tape across the door of unoccupied rooms. The tape was then to be dated, timed, and initialed by staff. There was no monitoring process to ensure this plan is effective to prevent patient access to these rooms.


Observation of Units 1 and 2 on March 8, 2017, at 1350, revealed 14 unoccupied bedrooms (rooms numbered 111, 113, 115, 116, 117, 118, 209, 210, 211, 212, 214, 216, 217, and 218). All of the doors were taped. None of the doors were dated and timed with staff initials.


In an interview with Personnel #58 (Charge RN) on March 7, 2017, at 1400, she stated she knew that the unoccupied bedrooms were supposed to be taped but did not know that they were to be dated and timed with staff initials.



Observation on March 8, 2017, at 1100, of the corridors in patient areas, nurses' stations, dayrooms, recreation rooms, dining areas, and waiting areas on Units 1 and 2 revealed acoustical drop ceilings. There were no acoustical drop ceilings in any of the patient bedrooms on both units.


Observation on Unit 2 (the adolescent unit) on March 7, 2017, at 1030, with Personnel #52 (CCO) revealed the Quiet Therapy room at the end of one of the corridors. There was a set of double doors near the end of the hallway. The double doors were locked. On each side of the double doors was a door that entered the Quiet Therapy room. The first door into the therapy room had been repaired around the latch such that the latch assembly did not engage with the strike plate properly. The door was designed to automatically lock when closed; however, the latch would not engage with the strike plate unless someone forcibly pushed the door shut. The lock on the second door was installed such that it would not lock from the outside of the therapy room, but would lock from the inside of the room. The return air vent in the therapy room had a one inch gap between the vent and the ceiling. There were two other air vents in the ceiling. The drop ceiling, air vents, door hinges, and door handles were ligature risks.


In an interview with Personnel #52 (CCO) on March 7, 2017, at 1030, she stated:

1. She would have maintenance immediately repair the first door.

2. The second door should lock on both sides of the door.

3. The acoustical drop ceiling and air vents were a ligature risk.

4. The unsecured therapy room gave patients access to these ligature risks.


Observation on Unit 2 (the adolescent unit) the following day (March 8, 2017) at 1200, with Personnel #52 (CCO) revealed that neither of the two doors entering the Quiet Therapy room from the corridor had been repaired. Parked inside the therapy room was a housekeeping cart. The cart was unlocked and unattended. The following items were on the cart: mop, broom, dust pan with a three foot handle, various cleaning solutions, a bungie cord, a C battery, metal clips, and a wooden door wedge. One of the cleaning solutions was Encore Germ Thief. These items were accessible to patients.


Record review of the Encore Germ Thief label revealed a caution to "Keep out of reach of children" and to "Store in an area inaccessible to children." The active ingredient was n-Alkyldimethylbenzylammonium chlorides (a tuberculocidal, virucidal, pseudomonicidal and bacterial) in this cleaning solution.


Record review of information on Alkyldimethylbenzylammonium chlorides from the Centers for Disease Control (CDC) revealed the solution to be hazardous when inhaled, ingested, or applied to the skin and eyes.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1200, she stated the damaged door should have been repaired and the housekeeping cart should not have been stored in the Quiet Therapy room. She also stated the housekeeping cart should have been locked.


In an interview with Personnel #56 (Housekeeper) on March 8, 2017, at 1230, she stated she had stepped off the unit and had left the cleaning cart in the Quiet Therapy room. She also stated that this was not where the cart was supposed to be stored and it should have been locked.


Observation of room 213 (the signage said "Exam") on Unit 2 (the adolescent unit) with Personnel #52 (CCO) on March 8, 2017, at 1215, revealed the door was unlocked. Three free-standing chrome wire shelving units were in the room. The metal shelves were a ligature risk. The following items were on the shelves: plastic bags, numerous hygiene products, combs, electronics, and an elastic band. The plastic bags and elastic band were ligature risks. A lavatory faucet in the room posed a ligature risk. The bottom shelves did not have a splash barrier on them. The ceiling was a dropped ceiling.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1215, she stated the door to room 213 should be locked. She also stated the chrome wire shelving units, faucet, plastic bags, elastic band, and dropped ceiling were ligature risks.



Observation of the seclusion rooms on Units 1 and 2 on March 8, 2017, at 1000, with Personnel #52 (CCO) revealed one seclusion room on each unit. The seclusion bathrooms had faucets that were ligature risks. Any patient placed in these seclusion rooms have access to these ligature risks for self harm.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1000, she stated the faucets in the seclusion areas were ligature risks.



Observation on Units 1 and 2 on March 8, 2017, at 1100, revealed light weight furniture, especially the chairs, in the patient care areas - group rooms, day areas, and dining area. These furnitures could be used by patients to harm other patients and staff.


In an interview with CCO Heidi Pierce on March 8, 2017, at 1100, she stated patients eat in designated areas on both units.


In an interview with CEO Tim Sullivan on March 7, 2017, at 1000, he stated the money that was allocated for heavy weight furniture was used on renovations.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, interview, and record review, on March 7-8, 2017, the facility was not maintained in a manner that will ensure the safety of each patient as evidenced by 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) were on units with numerous ligature risks present and easily accessible. These five patients were on suicidal precautions. This poses a risk for current and potential patients with suicidal ideation on the adult and adolescent units.


Based on observation, interview, and record review, the facility failed to maintain the hospital environment in such as a manner as to promote the safety and well-being of patients as evidenced by 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) were placed on units with multiple ligature risks present. These five patients were on suicidal precautions. This poses a risk for current and potential patients with suicidal ideation on the adult and adolescent units. Refer to 482.41(a) - [A-0701].
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation, interview, and record review, the facility failed to maintain the hospital environment in such as a manner as to promote the safety and well-being of patients as evidenced by 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) bwere placed on units with multiple ligature risks present and easily accessible. These five patients were on suicidal precautions. This poses a risk for current and potential patients with suicidal ideation on the adult and adolescent units.


Findings included:


Record review of the Unit 1 Patient Census dated March 8, 2017, revealed 22 patients (patients #2 through #23) occupying 18 bedrooms (rooms numbered 101, 102, 103, 104, 105, 106, 107, 108, 112, 114, 119, 120, 121, 122, 123, 124, 125, and 126). Two patients were on suicide precautions: Patient #20 and Patient #2.


Record review of the medical record for Patient #20:

1. Registration Record revealed admitted /time of March 7, 2017, at 1950.

2. Initial Psychiatric Evaluation by Personnel #64 (MD) dated March 8, 2017, at 1630, revealed, "Worsening of psychotic and depressive symptoms ... increase auditory hallucinations 'to hurt myself' ... active suicidal ideation."

3. Psychiatric Admission Orders by Personnel #64 (MD) dated March 7, 2017 at 1812 revealed suicide precautions.


Record review of the medical record for Patient #2:

1. Registration Record revealed admitted /time of February 28, 2017, at 1731.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 1, 2017, at 1235, revealed, "Suicidal thoughts ... auditory hallucinations ... worsening psychosis and suicidal ideation [with] intent ... schizophrenia, paranoid type."

3. Physician's Admitting Orders by Personnel #63 (MD) dated February 28, 2017, at 2224, revealed suicide precautions.

4. Physician Orders by Personnel #64 (MD) dated March 1-8, 2017, at various times revealed renewal of suicide precautions.


Record review of the Unit 2 Patient Census dated March 8, 2017, revealed 11 patients (patients #24 through #34) occupying 10 bedrooms (rooms numbered 205, 206, 207, 208, 219, 220, 221, 222, 223, and 224). Three patients were on suicide precautions: Patient #34, #32, and Patient #27.


Record review of the medical record for Patient #34:

1. Registration Record revealed admitted /time of March 8, 2017, at 0043.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 8, 2017, at 2333, revealed, "Depression ... with suicidality ... took an overdose ... remains suicidal ... with persistent suicidal urges and plans."

3. Admission Orders by Personnel #62 (MD) dated March 7, 2017, revealed suicide precautions.

4. Physician Orders by Personnel #62 (MD) dated March 8, 2017 revealed renewal of suicide precautions


Record review of the medical record for Patient #32:

1. Registration Record revealed admitted /time of March 8, 2017, at 0200.

2. Psychiatric Evaluation by Personnel #62 (MD) dated March 8, 2017, at 0704, revealed, "Depression ... with suicidality ... plans to drown ... or hang [herself] ... hallucinating."

3. Physician Orders by Personnel #62 (MD) dated March 8, 2017, revealed suicide precautions.


Record review of the medical record for Patient #27:

1. Registration Record revealed admitted /time of March 6, 2017, at 2225.

2. Physician's Admitting Orders by Personnel #63 (MD) dated March 6, 2017, at 2232, revealed suicide precautions.

3. Initial Psychiatric Evaluation by Personnel #54 (MD) dated March 7, 2017, at 0700, revealed, "Questionably suicidal ideation ... hallucinations."

4. Physician Orders by Personnel #54 (MD) dated March 8, 2017 at 0900 revealed renewal of suicide precautions.


Observation of Unit 1 on March 8, 2017, at 1200, revealed 24 patient bedrooms: 18 bedrooms were occupied by patients (rooms numbered 101, 102, 103, 104, 105, 106, 107, 108, 112, 114, 119, 120, 121, 122, 123, 124, 125, and 126) and six were empty (rooms numbered 111, 113, 115, 116, 117, and 118). All 24 bedrooms had the following ligature risks: push-pull door handles and architectural grade butt hinges on the doors opening into the bedrooms from the hallway, faucets, and air vents. These ligature risks were easily accessible to patients.


Observation of Unit 2 on March 8, 2017, at 1230, revealed 18 patient bedrooms: ten bedrooms were occupied by patients (rooms numbered 205, 206, 207, 208, 219, 220, 221, 222, 223, and 224) and eight were empty (rooms numbered 209, 210, 211, 212, 214, 216, 217, and 218). All 18 bedrooms had the following ligature risks: push-pull door handles and architectural grade butt hinges on the doors opening into the bedrooms from the hallway, faucets, and air vents. These ligature risks were easily accessible to patients.


During observations on Unit 1 on March 8, 2017, at 1200, Personnel #52 (CCO) and Personnel #55 (MHT) were present. A sheet was successfully tied around the faucet located in bedroom #120. The knot held firm when the sheet was pulled forcibly to both sides and the front of the sink. Next, a knot was tied in one corner of the sheet. The sheet was wedged across the top of the highest door hinge. The door was then shut with the knot on the outside of the door and the remainder of the sheet inside the door. The knot held firm when the sheet was pulled forcibly. Push-pull door handles were on the door. A metal air vent was in the room. Both provided ligature risks to patients.


In interviews with Personnel #52 (CCO) and Personnel #55 (MHT) on March 8, 2017, at 1200, both stated that the faucets found in the patient's rooms were ligature risks. Personnel #52 (CCO) further stated the door hinges and handles found on all of the bedroom doors and metal air vents in all of the patient rooms were ligature risks.


In an interview with Personnel #52 (CCO) on March 7, 2017, at 0900, she stated:

1. The doors to the patient's rooms do not lock.

2. Patients are not allowed to go into unoccupied bedrooms.

3. A system had been put into place so that tape is placed across the door of unoccupied rooms and then dated, timed, and initialed by staff.


Record review of the Plan for Patient Safety Regarding Ligature Risk and Suicide Risk by Personnel #52 (CCO), dated March 3, 2017, at 1638, revealed a plan to put tape across the door of unoccupied rooms. The tape was then to be dated, timed, and initialed by staff. There was no monitoring process in place to ensure the effectiveness of this plan.


Observation of Units 1 and 2 on March 8, 2017, at 1350, revealed 14 unoccupied bedrooms (rooms numbered 111, 113, 115, 116, 117, 118, 209, 210, 211, 212, 214, 216, 217, and 218). All of the doors were taped. None of the doors were dated and timed with staff initials.


In an interview with Personnel #58 (Charge RN) on March 7, 2017, at 1400, she stated she knew that the unoccupied bedrooms were supposed to be taped but did not know that they were to be dated and timed with staff initials.


Observation on March 8, 2017, at 1100, of the corridors in patient areas, nurses' stations, dayrooms, recreation rooms, dining areas, and waiting areas on Units 1 and 2 revealed acoustical drop ceilings. There were no acoustical drop ceilings in any of the patient bedrooms on both units.


Observation on Unit 2 (the adolescent unit) on March 7, 2017, at 1030, with Personnel #52 (CCO) revealed the Quiet Therapy room at the end of one of the corridors. There was a set of double doors near the end of the hallway. The double doors were locked. On each side of the double doors was a door that entered the Quiet Therapy room. The first door into the therapy room had been repaired around the latch such that the latch assembly did not engage with the strike plate properly. The door was designed to automatically lock when closed; however, the latch would not engage with the strike plate unless someone forcibly pushed the door shut. The lock on the second door was installed such that it would not lock from the outside of the therapy room, but would lock from the inside of the room. The return air vent in the therapy room had a one inch gap between the vent and the ceiling. There were two other air vents in the ceiling. The drop ceiling, air vents, door hinges, and door handles were ligature risks to patients.


In an interview with Personnel #52 (CCO) on March 7, 2017, at 1030, she stated:

1. She would have maintenance immediately repair the first door.

2. The second door should lock on both sides of the door.

3. The acoustical drop ceiling and air vents were a ligature risk.

4. The unsecured therapy room gave patients access to these ligature risks.


Observation on Unit 2 (the adolescent unit) the following day (March 8, 2017) at 1200 with Personnel #52 (CCO) revealed that neither of the two doors entering the Quiet Therapy room from the corridor had been repaired. Parked inside the therapy room was a housekeeping cart. The cart was unlocked and unattended. The following items were on the cart: mop, broom, dust pan with a three foot handle, various cleaning solutions, a bungie cord, a C battery, metal clips, and a wooden door wedge. One of the cleaning solutions was Encore Germ Thief.


Record review of the Encore Germ Thief label revealed a caution to "Keep out of reach of children" and to "Store in an area inaccessible to children." The active ingredient was n-Alkyldimethylbenzylammonium chlorides (a tuberculocidal, virucidal, pseudomonicidal and bacterial) in this cleaning solution.


Record review of information on Alkyldimethylbenzylammonium chlorides from the Centers for Disease Control (CDC) revealed the solution to be hazardous when inhaled, ingested, or applied to the skin and eyes.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1200, she stated the damaged door should have been repaired and the housekeeping cart should not have been stored in the Quiet Therapy room. She also stated the housekeeping cart should have been locked.


In an interview with Personnel #56 (Housekeeper) on March 8, 2017, at 1230, she stated she had stepped off the unit and had left the cleaning cart in the Quiet Therapy room. She also stated that this was not where the cart was supposed to be stored and it should have been locked.


Observation of room 213 (the signage said "Exam") on Unit 2 (the adolescent unit) with Personnel #52 (CCO) on March 8, 2017, at 1215 revealed the door was unlocked. Three free-standing chrome wire shelving units were in the room. The metal shelves were a ligature risk. The following items were on the shelves: plastic bags, numerous hygiene products, combs, electronics, and an elastic band. The plastic bags and elastic band were ligature risks. A lavatory faucet in the room posed a ligature risk. The bottom shelves did not have a splash barrier on them. The ceiling was a dropped ceiling. These ligature risks were accessible to patients.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1215, she stated the door to room 213 should be locked. She also stated the chrome wire shelving units, faucet, plastic bags, elastic band, and dropped ceiling were ligature risks.


Observation of the seclusion rooms on Units 1 and 2 on March 8, 2017, at 1000, with Personnel #52 (CCO) revealed one seclusion room on each unit. The seclusion bathrooms had faucets that were ligature risks.


In an interview with Personnel #52 (CCO) on March 8, 2017, at 1000, she stated the faucets in the seclusion areas were ligature risks.



Observation on Units 1 and 2 on March 8, 2017, at 1100, revealed light weight furniture, especially the chairs, in the patient care areas - group rooms, day areas, and dining area. These furnitures could be used by patients to harm other patients and staff.


In an interview with CCO Heidi Pierce on March 8, 2017, at 1100, she stated patients eat in designated areas on both units.


In an interview with CEO Tim Sullivan on March 7, 2017, at 1000, he stated the money that was allocated for heavy weight furniture was used on renovations.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, and record review, on March 7-8, 2017, the facility failed to protect and promote the rights of 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) to receive treatment in a safe environment as evidenced by the presence and easily accesible multiple ligature risks in the patient care areas.


Based on observation, interview, and record review, the facility failed to promote and protect the rights of each patient to receive treatment in a safe setting as evidenced by 5 of 33 patients (patient #2, #20, #27, #32, and patient #34) were placed on units with multiple ligature risks present and easily accessible. These five patients were on suicidal precautions. This poses a risk for current and potential patients with suicidal ideation on the adult and adolescent units.


Based on observation, interview, and record review, the facility failed to promote and protect the rights of each patient to receive treatment that meet their needs as evidenced by incomplete and inaccurate suicide self-harm assessments done by staff on 3 of 6 patients (patient #1, #6, and patient #11).


Refer to 482.13(c)(2) - [A-0144] and 482.13(c)(3) - [A-0142].