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.

MENTAL HEALTH INSTITUTE 1200 EAST WASHINGTON STREET MOUNT PLEASANT, IA Nov. 26, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, policy review, documentation review and staff interviews, the Psychiatric Unit staff failed to implement systems to ensure a safe environment for patients with a psychiatric diagnosis. The hospital had a census of 8 inpatients in the Adult Psychiatric Unit at the beginning of the investigation. The following examples confirm this determination.

The psychiatric unit staff failed to identify and remove or replace non-breakaway (anti-ligature) hardware from unit shower/bathroom doors, hallway doors, and patient bedroom doors after an attempted hanging by a patient with a sheet tied around his neck and attached to a non-breakaway door handle. Several staff members on duty walked by the patient with a sheet tied around his neck and attached the sheet to a non-breakaway door handle in the hallway. Staff failed to immediately attend to the patient. Refer to A 144.

The psychiatric unit staff failed to maintain a safe environment for suicidal patients by failing to minimize risk factors related to the non-breakaway handles on the doors in patients' bedrooms and bathrooms following the attempted hanging on October 19, 2014. Refer to A 144.

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure the safe care and monitoring of psychiatric inpatients and prevent self-injury.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, review of policy and procedures, associated documentation, medical record review, and staff interviews, the psychiatric hospital failed to establish and maintain a safe environment for 27 of 27 doors accessible to patients including 10 of 10 adult patient room doors. Psychiatric administrative staff failed to identify, remove or replace non-breakaway door handles from men's and women's shower/bathroom doors, hallway doors and patient bedroom doors. The hospital staff identified a census of 8 patients in the Adult Psychiatric Unit at the beginning of the survey.

Non-breakaway door handles provided a point of attachment for Patient #1 to tie a sheet to the door handle and around his neck in an attempted hanging as the patient dropped to the floor resulting in the sheet becoming taunt. This resulted in an unsafe environment for patients in the psychiatric unit.

Findings include:

1. Review of hospital documentation and review of video on 11/24/14 showed Patient #1 tied a sheet around his neck and tied the other end of the sheet to the men's bathroom door handle and slid slowly to the floor on 10/19/14. The hospital video identified 3 Patient #1 was trying to hang himself

Timeline from video of 10/19/14 incident with Patient #1 showed the following events.
At 10:25:28 Staff E, Resident Treatment Worker (RTW), walked from dayroom toward patient rooms, paused briefly but continued to proceed down the hall toward the patients' rooms.

At 10:25:52 Patient #1 was seen walking in the opposite direction down the hallway toward the men ' s bathroom with a sheet tied around his neck.

At 10:26:00 Patient #1 was at a doorway just before and across the hall from the men's bathroom. Staff F, RTW was seen walking toward the dayroom from the patient rooms. Staff F walked past Patient #1, who at this time was standing in the corner at the men's bathroom door facing the wall/door with the sheet tied around his neck. Staff F proceeded a short distance down the hall and motioned to Staff G, RTW. Staff F continued to stand with arms crossed facing north and was looking down toward the patient rooms from the entrance to the dayroom.

At 10:26:43 Staff G walked down the hall and glanced at Patient #1 as the patient was tying the sheet around the handle on the men ' s bathroom door. Staff G continued to walk toward the dayroom. Once near the dayroom Staff G walked further into the dayroom.

At 10:26:43 Patient #1 slid down the wall onto the floor with the sheet tied to the door and still tied around his neck.

At 10:26:43 Staff E, RTW walked toward Patient #1 while the patient was on the floor with the sheet taut around his neck and still tied off to the door handle.

At 10:27:54 Staff H, Registered Nurse (RN), charge nurse along with Staff E, RTW walked at normal pace down the hallway toward Patient #1. Staff H looked toward Patient #1.

At 10:28:00 Staff H, RN took a restraint cutter out of her pocket.

At 10:28:15 Staff H attempted to cut the sheet off the door. Staff E, RTW was in front of Patient #1 watching this. Staff G, RTW was standing in the hall watching as well. Another patient is also in the hall with no apparent direction from staff or assistance to leave the area given the potential impact on that patient.

At 10:28:34 the other patient walked out of camera range.

At 10:28:39 Staff F walked toward the scene, looked and continued down the hallway.

At 10:28:27 Staff H, RN was unable to cut the sheet and stopped to look at the cutter.

At 10:28:43 Staff E, RTW was given the cutter by Staff H, RN.

At 10:28:54 Staff E had successfully cut the sheet off the door and Staff H, RN, who had moved to the front of Patient #1, removed the patient's shoes from the area.

At 10:29:00 Staff G and Staff H walked down the hall leaving Staff E with the patient.

At 10:29:13 Patient #1 had the sheet pieces that had been cut from his neck in his hands.

At 10:29:19 Patient #1 re-tied the sheet piece around his neck and Staff E looked on. At the same time, Staff I, RTW, came down the hall as a silent code was called. Staff H, RN unlocked restraint room #2.

At 10:29:43 Staff F brought blue sweatpants for Patient #1. Once a patient was placed on suicide precautions, the patients were given blue sweats to wear.

At 10:29:47 Patient #1 took the sheet from his neck and dropped the sheet pieces to his side.

At 10:29:54 additional staff, Staff J, RTW, and Staff K, RTW, came down the hall from from the dayroom. At that time Patient #1 was able to get up and stand on his own.

At 10:29:59 Staff K, RTW, picked up the sheet Patient #1 had thrown to his side.

At 10:30:03 Patient #1 ambulated to restraint room #2 with blue sweatpants in hand. No staff entered the restraint room with Patient #1. All staff remain in the hall while Patient #1 was changing clothes behind the closed door. Staff H, RN appeared to be checking through the window.

At 10:30:21 Patient #1 handed out his clothing and Staff H gave Patient #1 a sweatshirt through the door.

At 10:31:21 Patient #1 came out of the restraint room and walked to the dayroom. All the staff from the hallway followed the patient.

At 10:33:29 Patient #1 moved a chair toward a window in the dayroom/kitchen and then nothing from this camera angle could be seen.

Staff H, RN failed to complete a physical assessment of Patient #1 after the patient's attempted hanging. Patient #1 continued to be on suicide watch.

2. Review of Patient #1's medical record showed the patient was admitted on [DATE] with history of substance abuse and disruptive and abusive behavior. Patient #1 had been on suicide precautions 10 times between 2/25/14 and 10/20/14 but was not on suicide precautions at the time of the attempted hanging.

3. Observations of the adult psychiatric unit on 11/24/14 at 11:45 AM revealed the following:

a. At 11:45 AM, during the tour of the Adult Psychiatric Unit, with Staff A, Administrator of Nursing, revealed 1 of 1 unlocked door to the men's bathroom, located in the patient rooms hallway with a C-shaped handle on the outside of the door approximately 52.75 inches above the floor protruding approximately 2 inches from the door. The same door had a C-shaped handle on the inside of the door approximately 41.5 inches above the floor protruding approximately 1.5 inches from the door. The Administrator of Nursing verified the door handles were not break away handles and patients were not supervised by staff when in the bathroom. Patients could attach a sheet to the door handles if attempting suicide by hanging.

b. Observations for 1 of 1 unlocked door to the women's bathroom, located in the patient rooms hallway revealed a C-shaped handle on the inside of the door approximately 44.25 inches above the floor protruding approximately 1.5 inches from the door. The Administrator of Nursing verified the door handles were not break away handles and patients were not supervised by staff when in the bathroom. Patients could attach a sheet or other item to the door handle if attempting suicide by hanging.

c. Observations for 10 of 10 patient rooms revealed L-shaped door handles on the inside and outside of the patients' room doors. The handles were approximately 40 inches above the floor protruding 1.5 inches from the door. The Administrator of Nursing verified the door handles were not break away handles and patients could be in their rooms and not supervised by staff. Patients could attach a sheet to other item to the door handles if attempting suicide by hanging.

d. Observations for 2 of 2 seclusion rooms revealed a C-shaped handle on the outside of each door approximately 48 inches above the floor protruding approximately 1.5 inches from the door. The Administrator of Nursing verified the door handles were not break away handles and patients could be unsupervised by staff in the hallway. Patients could attach a sheet or other item to the door handles if attempting suicide by hanging.

e. Observations for 8 of 8 doors in the patient hallway (storage room, staff bathroom, treatment room, quiet room, conference room x 2, laundry room, and janitor closet) and 2 of 2 doors in the day room revealed L-shaped door handles on the hallway side of the doors. The handles were approximately 40 inches above the floor protruding 1.5 inches from the door. The Administrator of Nursing verified the door handles were not break away handles and patients could be unsupervised by staff in the hallway. Patients could attach a sheet or other item to the door handles if attempting suicide by hanging.

f. Observations for 2 of 2 doors in the patient hallway and 1 of 1 door in the day room to the nurse's station revealed door knobs approximately 40.5 inches from the floor and protrude approximately 3 inches from the door. The Administrator of Nursing verified the door knobs were not break away knobs and patients could be unsupervised by staff in the hallway. Patients could attach a sheet to the door handles if attempting suicide by hanging.

4. During an interview on 11/24/14 at 1:00 PM, the Administrator of Nursing acknowledged the environmental safety concerns identified by the surveyor.

5. Review of the policies and procedures showed the administrative staff failed to develop and implement policies and procedures that ensured the safety of adult psychiatric patients by establishing breakaway points for the door handles accessible to the patients in the patient rooms and patient hallway.

During an interview on 11/26/14 at 9:50 AM, the Administrator of Nursing acknowledged the hospital failed to develop and implement policies and procedures that ensured a safe environment for the safety of adult psychiatric patients by establishing breakaway points for the door handles accessible to the patients in the patient rooms and patient hallway.

6. Psychiatric staff interviews on 11/24/14 revealed the following information:

a. At 4:40 PM, Staff B, Registered Nurse, stated adult psychiatric patients could be in their assigned rooms with the door closed and staff monitor the patient by checking on the patients every 15 minutes.

b. At 5:05 PM, Staff C, Resident Treatment Worker, verified the adult psychiatric patients could be in their room with the door closed and staff would check on the patients every 15 minutes.

c. At 5:30 PM, Staff D, Resident Treatment Worker, verified the adult psychiatric patients could be in their room with the door closed and staff would check on the patients every 15 minutes.

7. Review of open medical records revealed patients had prior suicide attempts/ideations by hanging documented in 2 of 8 open records reviewed. Psychiatric staff had access to these records and should have known they cared for patients with history of suicide attempts/ideations by hanging.