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HILLCREST HOSPITAL CLAREMORE 1202 N MUSKOGEE PLACE CLAREMORE, OK 74017 April 4, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, and interview, the hospital failed to ensure the safety of six of six patients (Patients #1 through 6) in the Behavioral Health Unit admitted for behavioral disturbances including agitation, confusion, paranoia, delusions, and hearing voices by:

1. Allowing patients into unlocked, chain link fenced outside patio area with light weight, non-ligature free furniture, outside water faucet, exposed metal utility pipes, and access to glass windows;

2. Bulletin boards with non-ligature free mountings in Day Room;

3. Exposed electrical outlets in the hallway;

4. Light weight, open-armed, and open-legged structured chairs in the hallway and in patient rooms;

5. Light weight, rolling over-the-bed tables in the hallway;

6. Door latches with Phillips-head screws in door frames;

7. Window latches in "suicide watch" rooms(Rooms 139 and 142) mounted with Phillips-head screws;

8. Glass windows in patient rooms (including the "suicide watch" rooms);

9. Sharp-edged openings in door frames where hinges had been removed;

10. Wicket doors with rough-edged, splintered edges;

11. Shower room with non-ligature free fixtures, hand held shower head, shower curtain and light weight chair next to shower.

Refer to Tag-A-0144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, and interview, the hospital failed to ensure the safety of six of six patients (Patients #1 through 6) in the Behavioral Health Unit admitted for behavioral disturbances including agitation, confusion, paranoia, delusions and hearing voices by:

1. Allowing patients into unlocked, chain link fenced outside patio area with light weight, non-ligature free furniture, outside water faucet, exposed metal utility pipes and access to glass windows;

2. Bulletin boards with non-ligature free mountings in Day Room;

3. Exposed electrical outlets in the hallway;

4. Light weight, open-armed and open-legged structured chairs in the hallway and in patient rooms;

5. Light weight, rolling over-the-bed tables in the hallway;

6. Door latches with Phillips-head screws in door frames;

7. Window latches in "suicide watch" rooms(Rooms 139 and 142) mounted with Phillips-head screws;

8. Glass windows in patient rooms (including the "suicide watch" rooms);

9. Sharp-edged openings in door frames where hinges had been removed;

10. Wicket doors with rough-edged, splintered edges;

11. Shower room with non-ligature free fixtures, hand held shower head, shower curtain and light weight chair next to shower.


This failed practice had the likelihood to result in an increased risk of harm to patients in the Behavioral Health Unit by not providing an environmentally safe area for patients with behavioral disturbances.

Finding:

On 04/04/19 at 12:30 pm, surveyors observed the following:

Day Room:

1. Contained light-weight chairs with open armed and open legged structure.

2. Bulletin boards mounted to walls; the large bulletin boards were not ligature free mountings. Could be pulled from the walls, screws at each corner.


Patio/Yard:

1. Back gate was open. There was a small lock (less than an inch in size) hanging around a chain that was not secured; the back gate opens to a parking lot.

2. Water faucet accessible.

3. Utility pipe; Staff H stated, he was unsure what the pipe was for (next to the water faucet).

4. Patio furniture was light weight, open-holed, metal with a leaf design and sharp edges.

5. Chain link fence around area with plastic strips running through the links.

6. There was some type equipment room next to enclosed area.

7. The patio backs up to the patient windows; the windows are glass in most rooms.

8. Unlocked electrical outlet.


Shower Room:

This is large, regular bathroom with shower curtain, hand-held shower head and light weight chair; none of the fixtures are ligature free.


Patient Rooms:

1. Glass windows were noted in most rooms including "suicide rooms."

2. Wicket doors with rough wood and splintered edges all around; sharp edges around the frames.

3. Small bar of soap was found in Patient #5's room. Staff B states they use small bars of soap instead of giving full bar regardless of patient's diagnosis.

4. Window latches in the two "suicide rooms" contained Phillips-head screws.

5. Light weight chairs with open-armed and open-legged structure.

6. Door latches with Phillips-head screws in door frames.

7. Sharp-edged openings in door frames where hinges have been removed.


Hallway:

1. Light weight, open-armed and open-legged chairs.

2. Exposed electrical outlets.

3. Light weight, rolling over-the-bed tables


A review of the medical records of the six patients currently on this unit showed:

1. Two patients (Patients #4 and 6) were admitted with chief complaint of confusion and agitation.

2. Patient #2 was admitted with chief complaint of confusion and agitation combativeness.

3. Patient #5 was admitted with chief complaint of paranoid delusion.

4. Patient #3 was admitted with chief complaint of hearing voices.

5. Patient #1 was admitted with chief complaint of dementia and delusions.


On 04/03/19 at 8:30 am, Staff A and H stated they had not recognized the safety issues being discussed by surveyors.

On 04/04/19 at 9:00 am, Staff A, H and I stated they were unaware of the problems with the patio.