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.

Based on observations, interview, and record review the facility failed to ensure the hospital protected and promoted each patients' rights according to the Condition of Participation: CFR 482.13 Patient's Rights. findings:

A-144 Patients Rights: Care in Safe Setting
A bathroom, located in the hospital emergency department located on the hallway, used for behavioral health patients, was found to be unlocked. Further investigation revealed behavioral health patients were sometimes allowed to use that bathroom unsupervised.This failed practice placed those patients at immediate risk for injury and/or death from self-harming behaviors. The facility was notified of the immediate jepardy for those patients on 12/27/18 at 10:15 am and had implimented measures to mitigate the risk to the patients on 12/27/18 at 4:00 pm.
Refer to A-144 for findings.


Based on observation, interview and record review the facility failed to ensure the safety of patients by removing ligature and weapons risk in the Emergency Department (ED) area that was dedicated to the acute care of Behavioral Health Patients (BHP). Specifically, the facility failed to identify a bathroom located on the unit, as an injury or suicide risk and take consistent measures to ensure the bathroom was secured and/or BHP were monitored at all times during its use. This failed practice placed BHP #1 and had placed BHP #2, out of 4 BHP reviewed from the ED, and all potential future BHP patients at immediate risk for injury and/or death from self-harming behaviors. Findings:

The facility was notified of the immediate jeopardy to the well-being and/or safety of BHP using that room in the ED on 12/27/18 at 10:15 am.

The Facility put measures into place to remove the immediate risk to BHP receiving care in the ED on 12/27/18 at 4:00 pm.

Observation on 12/26/18 at 2:20 pm of the hall way, designated for behavior health located in the ED, revealed, a bathroom door that was unlocked. The door could be locked from the inside, and required a hex key to unlock the door from the outside. There was no hex key or device to unlock the door in the immediate area.

Inside were multiple fixtures a BHP could use for strangulation and/or as weapons to harm themselves or others to include:

- shower head with a nozzle that may allow for ligature attachment;
- a hand held shower attached to a 5-6 foot, stainless steel hose attached to a slider bar;
- shower faucets with handles;
- double sided hooks on the inside of the shower room door;
- glass mirror;
- garbage can with a plastic liner;
- wall mounted garbage receptacle with flip lid;
- toilet seat;
- wire wall rack;
- bench seat located near the shower head that lifts up and down;
- toilet seat covers in a plastic mounted dispenser; and
- 2 stainless steel mounted hand rails.

Further observation of the interior of the bathroom revealed the ceiling height to be approximately 9 - 10 feet. The escutcheon plate around the single sprinkler head had been removed and it appeared paper had been crumpled and placed around the sprinkler.

Observation of the BH hall on 12/26/18 at 2:20 pm in the ED revealed a waiting room with 2 large (33 gallon) garbage bags with plastic bag liners. The door to the waiting room was open and unlocked.

During the observation on 12/26/18 at 2:20 pm BHP #1 was observed in a patient room, directly across the hall from the unsecured bathroom.

Observation of the unit revealed BHP #1 was being monitored in the room by video camera. The video feed was directed to a screen at the nurse's station, located down the hall, where staff sat at the desk inside the nurse's station and monitored the video feed.

Further observation revealed the hex key was kept in a drawer, inside the nurse's station.

Record review on 12/26-27/18 revealed BHP #1 had diagnosis that included depression.

During an interview on 12/26/18 at 2:20 pm BH Technician (BHT) #1 stated that the bathroom door should be locked. When asked how the bathroom was monitored, BHT stated a few BHPs required staff in the bathroom while the patient showered. The BHT stated most often staff stood right outside the closed bathroom door. During the interview BHT #1 stated that a few months ago, a BHP has attempted suicide by strangulation in the bathroom and since the incident, the bathroom was supposed to remain locked.

During an interview on 12/26/18 at 2:45 pm the ED Manager stated staff was to be with a BHP in the bathroom, or in the hall with the door ajar. When asked how the escutcheon plate, around the sprinkler, could have been removed and papers stuffed up around the sprinkler head, the ED Manager stated it was concerning but that it had not been addressed as they are just now aware of the concern.

Review of BHP #2's medical record revealed on 11/3/19 at 8:45 am, BHP #2 was discovered in the same bathroom with the cord of the blood pressure machine wrapped around his/her neck.

Review of BHP #2's medical record on 12/26-27/18 revealed BHP #2 (MDS) dated [DATE] with diagnoses that included depression and a history of suicide attempts.

Review of a physician's note, dated 11/2/18 revealed " ...presents today with suicidal ideation. The patient is resting in the ER [ED] and will be seen by behavioral health in the morning ....the patient is on one-on-one monitoring in addition to video monitoring ..."

Review of the "Restraint/Seclusion Observation Record", dated 11/3/18 at 8:45 am, revealed the patient was placed in locked seclusion for "attempted self-strangling."

During an interview on 12/27/18 at 8:20 am, the Quality Regulatory Consultant stated the door to that bathroom should have been locked.

During an interview on 12/27/18 at 8:30 am BHT #2 was asked if BHPs were allowed to shower alone in that bathroom. The BHT stated some BHPs could shower with the door closed and staff would stand in the hall and have frequent vocal checks with the patient.