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.

JOHNSON MEMORIAL HOSPITAL 201 CHESTNUT HILL ROAD STAFFORD SPRINGS, CT 06076 Dec. 20, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Condition of Patient Rights has not been met.

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that patients on the psychiatric unit were maintained in such a manner as to promote care in a safe setting when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.

Please see A144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that patients on the psychiatric unit were maintained in such a manner as to promote care in a safe setting when multiple ligature points were identified resulting in a finding of Immediate Jeopardy. The findings include:


On 12/19/17 at 11:00 AM and various times throughout the day, during tour of the 2nd floor adult psychiatric unit along with the Director of Facilities, and the Nurse Manager the following was observed:

1. Sleeping room numbers 27, 28, 29 and 30 had night lights and thermostats that were identified on a risk based assessment dated ,d+[DATE] conducted by a contractor for the hospital. The assessment identified these as ligature risks and the facility was in the process of removing these ligature risks as part of a mitigation plan following the October 2017 assessment but had not completed mitigation of all the identified hazards prior to the survey. During the survey on 12/19/17, the Life Safety Code Surveyor was able to demonstrate that one of the night lights could bear the load of a person. There was no additional staff supervision and/or environmental rounds conducted while the hospital was removing the identified risks prior to the survey.

2. The B lounge had a corner TV stand with a DVD player attached to its underside that could be utilized as a ligature point. Lockers with hasps and locks also had not been identified by the risk based assessments as possible ligature points. The TV stand, DVD player and hasp locks all had spaces where an object/item acould be threaded through and used as a liagure point.

3. The handicap bathroom had faucet controls and a faucet that were ligature risks. The facucet and faucet controls protruded in a manner that would allow an item to be treaed around and used as a ligature point.

4. The affected patient sleeping rooms, the B lounge, hasp locks and the handicap bathroom were accessible to unsupervised patients. Although these hazards were identified by the hospital, the hospital failed to conduct environmental rounds to ensure the safety of the patients. The hasp locks had spaces where an object/item acould be threaded through and used as a liagure point.

5. Review of clinical records identified a patient census of 14 with 9 of the 14 patients admitted with suicidal ideations. On 12/19/17, the clinical records of Patients #25 through #38 were reviewed. Psychiatrist assessments and every-shift nursing assessments of each patient's suicidality and self-harm risk were completed and identified that no patients currently admitted to the psychiatric unit were actively suicidal or at risk for self-harm. Care plans were updated daily to include each patient's safety risks. All 14 patients were on routine 15-minute observations. Two patients were on additional 5-minute checks; 1 for exhibiting elopement behaviors and 1 who was a new admission in the process of being assessed.


The hospital developed a plan to mitigate the environmental hazards on 12/19/17. On 12/20/17, the surveyors verified while onsite that the hospital implemented their plan, Immediate Jeopardy was removed and the deficiencies remain.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
The Condition of Participation for the Physical Environment has not been met.

Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that the psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy.

See A 701
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a tour of the hospital, review of hospital policies, hospital documentation and staff interviews, the hospital failed to ensure that the psychiatric unit including sleeping rooms were maintained in such a manner as to promote the safety and well-being of patients when multiple ligature points were identified resulting in a finding of Immediate Jeopardy. The findings include:


On 12/19/17 at 11:00 AM and various times throughout the day, during tour of the 2nd floor adult psychiatric unit along with the Director of Facilities, and the Nurse Manager the following was observed:

1. Sleeping room numbers 27, 28, 29 and 30 had night lights and thermostats that were identified on a risk based assessment dated ,d+[DATE] conducted by a contractor for the hospital. The assessment identified these as ligature risks and the facility was in the process of removing these ligature risks as part of a mitigation plan following the October 2017 assessment but had not completed mitigation of all the identified hazards prior to the survey. During the survey on 12/19/17, the Life Safety Code Surveyor was able to demonstrate that one of the night lights could bear the load of a person. There was no additional staff supervision and/or environmental rounds conducted while the hospital was removing the identified risks prior to the survey.

2. The B lounge had a corner TV stand with a DVD player attached to its underside that could be utilized as a ligature point. Lockers with hasps and locks also had not been identified by the risk based assessments as possible ligature points. The TV stand, DVD player and hasp locks all had spaces where an object/item acould be threaded through and used as a liagure point.

3. The handicap bathroom had faucet controls and a faucet that were ligature risks. The facucet and faucet controls protruded in a manner that would allow an item to be treaed around and used as a ligature point.

4. The affected patient sleeping rooms, the B lounge, hasp locks and the handicap bathroom were accessible to unsupervised patients. Although these hazards were identified by the hospital, the hospital failed to conduct environmental rounds to ensure the safety of the patients. The hasp locks had spaces where an object/item acould be threaded through and used as a liagure point.

5. Review of clinical records identified a patient census of 14 with 9 of the 14 patients admitted with suicidal ideations. On 12/19/17, the clinical records of Patients #25 through #38 were reviewed. Psychiatrist assessments and every-shift nursing assessments of each patient's suicidality and self-harm risk were completed and identified that no patients currently admitted to the psychiatric unit were actively suicidal or at risk for self-harm. Care plans were updated daily to include each patient's safety risks. All 14 patients were on routine 15-minute observations. Two patients were on additional 5-minute checks; 1 for exhibiting elopement behaviors and 1 who was a new admission in the process of being assessed.


The hospital developed a plan to mitigate the environmental hazards on 12/19/17. On 12/20/17, the surveyors verified while onsite that the hospital implemented their plan, Immediate Jeopardy was removed but the deficiencies remain.