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DANVILLE STATE HOSPITAL 50 KIRKBRIDE DRIVE DANVILLE, PA 17821 April 29, 2021
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on the systemic non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

482.41(a) Tag - 0701
Based on review of facility policy and documentation, observation and staff (EMP) interview it was determined the facility failed to eliminate ligature risks associated with electric bed power cords in four of the six behavioral health units (Units 210, 211, 310 and 311) of the hospital.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on review of facility policy and documentation, observation and staff (EMP) interview it was determined the facility failed to eliminate ligature risks associated with electric bed power cords in four of the six behavioral health units (Units 210, 211, 310 and 311) of the hospital.

Findings include:

Review on April 26, 2021, of facility policy "Plan for the Management of Safety," last approved April 8, 2021, revealed "...Policy: 1. To provide for a safe physical environment of care which is as free of hazards as possible, and to manage consumer and staff activities to reduce the risk of accident and injuries. All staff are tasked with the responsibility of insuring that a safe environment is provided and maintained. ... "

Review on April 26, 2021, of facility policy "Consumer Safety," last approved February 2020, revealed "...Policy: Danville State Hospital (DSH) will maintain an on-going, pro-active and reactive program for the identification and management of risks to consumer safety. Definition: Ligature Risk - A ligature risk (point) is defined as anything which could be used to attach a rope, cord, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures. Procedure: 1. All staff will receive training at the time of initial orientation and annually thereafter on consumer safety issues including ligature risk...10. On a monthly basis, risk assessment tours will be completed of all consumer living areas. The ligature risk Assessment Tool will be utilized during these tours. These tours utilize a proactive approach to the identification and resolution of potential safety issues. Aggregate data from the tours will be reviewed by the Executive Staff and a plan of action developed where applicable. ..."

Review on April 29, 2021, of facility training "Danville State Hospital Ligature Risk Module 02/2000" revealed "...Ligature Risks Did you know that...Hanging and strangulation are responsible for 75% of all deaths in psychiatric facilities. ... Key Terms...Ligatures Items used for tying or binding (example: cords or ropes)...Common Ligatures Anything with an attached cord or rope can be potentially uses as a ligature. Cables and cords are used similar to ropes. Consumers can detach cables from devices such as blood pressure machines, phones, blinds, etc. ..."

Observation on April 26, 2021, at approximately at 11:00 a.m. on patient care Unit 211, revealed electric beds in patient rooms 1113,1115, 1116, 1117, 1118A, 1118B and 1136. These beds had electrical cords over six feet in length extending from under the bed to the electrical wall outlet.

Interview with EMP7 on April 26, 2021, at the time of the observation confirmed the electric beds in patient rooms 1113,1115, 1116, 1117, 1118A, 1118B and 1136. EMP7 confirmed the length of these electrical cords posed a ligature risk to patients with suicidal ideation.

Observation on April 27, 2021, at approximately 10:00 a.m., on patient care Unit 210 revealed electric beds in rooms 2208, 2210, 2215, 2229 and 2235. These beds had electrical cords over six feet in length extending from under the bed to the electrical wall outlet.

Interview with EMP7 on April 27, 2021, at the time of the observation confirmed the electric beds in patient rooms 2208, 2210, 2215, 2229 and 2235. EMP7 confirmed the length of these electrical cords posed a ligature risk to patients with suicidal ideation.

Observation on April 27, 2021, at 1330 on patient care Unit 310 revealed electric beds in patient rooms 1210, 1218, 1226, 1227, 1228 and 1229. These beds had electric cords over six feet in length extending from under the bed to the electrical wall outlet.

Interview with EMP4 and EMP5, on April 27, 2021, at the time of the observation confirmed the electric beds in patient rooms 1210, 1218, 1226, 1227, 1228 and 1229. EMP4 and EMP5 confirmed the length of these electrical cords posed a ligature risk to patients with suicidal ideation.

Observation on April 27, 2021, at 1400 on patient care Unit 311 revealed electric beds in patient rooms 1105, 1111, 1123 and 1125. These beds had electric cords over six feet in length extending from under the bed to the electrical wall outlet.

Interview with EMP4 and EMP5, on April 27, 2021, at the time of the observation confirmed the electric beds in patient rooms 1105, 1111, 1123 and 1125. EMP4 and EMP5 confirmed the length of these electrical cords posed a ligature risk to patients with suicidal ideation.

Review on April 27, 2021, of facility documentation on its "Danville State Hospital Ligature Risk Assessment Form" revealed ligature risk assessments were performed on patient care units 211, 212, 213, 310, 311 and 312 on January 15, 2019, February 27, 2019, March 18 & 19, 2019, April 17, 2019, May 23, 2019, June 13, 2019, July 24, 2019, August 20, 2019, September 11, 2019, October 18, 2019 and November 14, 2019, identifying power cords on medical equipment (beds) as ligature risks on all units. The risk assessments did not identify the patient care rooms where power cords presented a ligature risk and did not provide data on the number of electrical beds with power cords that presented a ligature risk. Ligature risk assessments performed on September 22, 2020 and April 22, 2021, did not include an assessment of the electrical beds in the patient care units surveyed.

Interview with EMP8 on April 27, 2021, at approximately 10:30 a.m., confirmed the dates of the ligature risk assessments in 2019, 2020 and 2021. EMP8 further confirmed risk assessments were not performed in January 2020, February 2020, March 2020, April 2020, May 2020, June 2020, July 2020, August 2020, October 2020, November 2020, December 2020, January 2021, February 2021, and March 2021 due to the COVID-19 pandemic. EMP8 confirmed the risk assessments did not identify the patient care rooms where power cords presented a ligature risk and did not provide data on the number of electrical beds with power cords that presented a ligature risk. EMP8 confirmed the ligature risk assessments performed on September 22, 2020 and April 22, 2021, did not include an assessment of the electrical beds.

Review of facility documentation, "Danville State Hospital Safety Meeting" minutes on April 27, 2021, revealed the minutes for meetings in January, February, April, May, July, August and December of 2019, January, February, March, May, June, July, August, October, November and December of 2020 and April 21, 2021 noted ligature risk reports were received and distributed. There were no ligature risk assessment reports attached to a copy of the meeting minutes.

Interview with EMP8 on April 27, 2021, confirmed the meeting minutes for the 2019, 2020, and 2021 meetings above noted ligature risk reports received and distributed were "Danville State Hospital Ligature Risk Assessment Form". EMP8 further confirmed even though ligature risk assessments were not performed in December 2019, January, February, March, May, June, July, August, October, November and December of 2020 and April 21, 2021, the meeting minutes documented the reports had been received and distributed. EMP8 confirmed the documentation was incorrect.

Multiple requests were made throughout the survey to EMP1 and EMP8 for documentation of an action plan for mitigating the ligature risks identified during the facility's previous risk assessment rounds. No documentation was provided.

This is a repeat citation.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to ensure equipment in the dietary department was cleaned per the cleaning assignment schedules for six out of six months (January 2020, February 2020, March 2020, January 2021, February 2021 March 2021.
Findings include:
Review on April 29, 2021, of facility dietary policy "Cleaning Standards ... Cleaning Schedules," last reviewed August 13, 2020, revealed "1.0 There will be a posted cleaning schedule in the main kitchen and tray service regarding equipment, stating when the item should be cleaned and showing when it was cleaned and by which employee. 1.1 each piece of equipment 1.2 work surfaces 1.3 areas not part of routine scheduled cleaning 2.0 Cleaning schedules shall show: 2.1 when item is to be cleaned 2.2 when it was cleaned last 2.3 by whom it was cleaned 3.0 The production and meal service supervisor(s) shall randomly monitor the posted cleaning schedule for completion of task assignments. Assignments should be rotated monthly; schedules should be saved for a one-year period. 3.1 At the end of each month, the supervisor will review the cleaning schedule to determine if any cleaning was not completed as assigned. Appropriate action will be taken with the employee who is accountable for the cleaning assignment."
Observations on April 27, 2021, of facility dietary monthly cleaning schedules "Monthly Cleaning Assignments, Oven Cleaning Schedule Clean 2X Month and Cooks Cleaning Schedule," revealed 50 items to be cleaned. The cleaning schedules noted the equipment to be cleaned and how frequently it is to be cleaned, the name of the staff member assigned to that task and four-week spaces for documentation of when completed.
Review of January 2020, February 2020, March 2020, January 2021, February 2021, and March 2021, revealed numerous areas blanks when cleaning was not documented.
Review of Monthly Cleaning Assignments for January 2020 revealed 31 blanks where cleaning of the 17 pieces of equipment was not documented. Review of Monthly Cleaning Assignments for February 2020 revealed 27 blanks where cleaning of the 17 pieces of equipment was not documented. Review of Monthly Cleaning Assignments for March 2020 revealed 29 blanks where cleaning of the 17 pieces of equipment was not documented. Review of Monthly Cleaning Assignments for January 2021 revealed 27 blanks where cleaning of the 17 pieces of equipment was not documented. Review of Monthly Cleaning Assignments for February 2021 revealed 26 blanks where cleaning of the 17 pieces of equipment was not documented. Review of Monthly Cleaning Assignments for March 2021 revealed 35 blanks where cleaning of the 17 pieces of equipment was not documented.
Review of Oven Cleaning Schedule for January 2020 revealed 12 blanks where cleaning of the nine ovens was not documented. Review of Oven Cleaning Schedule for February 2020 revealed 15 blanks where cleaning of the eight ovens was not documented. Review of Oven Cleaning Schedule for January 2021 revealed 4 blanks where cleaning of the eight ovens was not documented. Review of Oven Cleaning Schedule for February 2021 revealed 15 blanks where cleaning of the eight ovens was not documented. Review of Oven Cleaning Schedule for March 2021 revealed 8 blanks where cleaning of the eight ovens was not documented.
Review of Cooks Cleaning Schedule for January 2020 revealed 56 blanks where cleaning of the 20 pieces of equipment was not documented. Review of Cooks Cleaning Schedule for February 2020 revealed 62 blanks where cleaning of the 20 pieces of equipment was not documented. Review of Cooks Cleaning Schedule for March 2020 revealed 46 blanks where cleaning of the 20 pieces of equipment was not documented. Review of Cooks Cleaning Schedule for January 2021 revealed 53 blanks where cleaning of the 20 pieces of equipment was not documented. Review of Cooks Cleaning Schedule for February 2021 revealed 63 blanks where cleaning of the 20 pieces of equipment was not documented. Review of Cooks Cleaning Schedule for March 2021 revealed 61 blanks where cleaning of the 20 pieces of equipment was not documented.
Interview with EMP3, on April 27, 2021, at 1055, confirmed the dietary monthly cleaning schedules with no documentation of cleaning for numerous areas. EMP3 confirmed staff is to date and initial the schedule when they have completed the task.
Interview with EMP1 and EMP2, on April 27, 2021, at 1130, confirmed the dietary monthly cleaning schedules with no documentation of cleaning for for numerous areas. EMP2 confirmed staff is to date and initial the schedule when they have completed the task.