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Based on observations, record reviews, and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

Review of the hospital's policy titled "PC-803: Patient Rights and Responsibilities" effective date 08/06/2012, revealed in part, "Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned".

Observation on 12/16/2024 at 10:15 a.m. - 10:55 a.m. of the hospital accompanied by S1CEO, S2DON, S3CD, and S4CO revealed in the bathroom of rooms 'a', 'b', 'f', and 'h' there was a gap between the toilet and the wooden built-in creating an anchor point and ligature risk. During the observation at 10:43 a.m. in room 'f' S3CD was observed to get a sheet around the toilet through the gap between the toilet and the wooden built-in. In the bathrooms of rooms 'b' and 'g' there were 2 handrails in each shower that had a gap between the wall and handrail creating an anchor point and ligature risk. In the bathrooms of rooms 'a', 'b', 'f', 'h', 'g', and 'e' the shower outlet had to be connected to a hose that the shower head was attached to creating a ligature risk.

In an interview during the observation S1CEO and S3CD verified the above stated findings.

Observation on 12/17/2024 at 2:24 p.m. - 2:40 p.m. of the hospital accompanied by S3CD revealed in the bathroom of rooms 'd' and 'c' there was a gap between the toilet and the wooden built-in creating an anchor point and ligature risk. In the bathrooms of rooms 'd' and 'c' the shower outlet had to be connected to a hose that the shower head was attached to creating a ligature risk.

In an interview during the observation S3CD verified the above stated findings. S3CD verified all showers are the same in all patient bathrooms and requires the hose with the shower head to be connected to the outlet to be able to use the shower.

Observation on 12/17/2024 at 2:24 p.m. - 2:40 p.m. of the 2 shower heads with the hose attached revealed each hose was approximately 4 foot in length making the hose a safety risk for patients.

In an interview during the observation S1CEO and S3CD verified the 2 shower heads with the hose attached revealed each hose was approximately 4 foot in length.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) who performed the face-to-face evaluation after the initiation of restraints or seclusion consulted with the attending physician or other licensed practitioner as soon as possible after the evaluation for 1 (#3) of 3 (#1, #2, #3) patient records reviewed.

Findings:

Review of the hospital's policy titled "PC-1502: Restraints and Seclusion Use" revised 03/18/2024, revealed in part, "l. If the face-to-face evaluation is conducted by someone other than the patient's attending physician, the person completing the face-to-face evaluation must consult the attending physician or other licensed independent practitioner who is responsible for the care of the patient as soon as possible after the completion of the 1-hour face-to-face evaluation."

Review of Patient #3's medical record revealed an admission date of 11/07/2024. Further review of the record revealed restraints were initiated on 11/24/2024 at 10:29 a.m. and discontinued at 11:50 a.m. Review of the restraint documentation, the 1 hour face-to-face evaluation was conducted by S5RN on 11/24/2024 at 11:20 a.m. Further review of the restraint documentation failed to reveal documentation of the RN consulting with the attending physician as soon as possible after the completion of the 1 hour face-to-face evaluation.

Further review of Patient #3's medical record revealed restraints were initiated on 11/24/2024 at 6:15 p.m. and discontinued at 8:15 p.m. Review of the restraint documentation, the 1 hour face-to-face evaluation was conducted by S5RN on 11/24/2024 at 7:15 p.m. Further review of the restraint documentation failed to reveal documentation of the RN consulting with the attending physician as soon as possible after the completion of the 1 hour face-to-face evaluation.

In an interview on 12/17/2024 at 1:01 p.m. S3CD verified there was no documentation of the RN consulting with the physician after the completion of the 1 hour face-to-face evaluation for both restraint occurrences included in Patient #3's medical record.

Based on record reviews and interview, the hospital failed to ensure there was documentation of alternatives or less restrictive interventions attempted prior to initiating the use of restraints for 1 (#3) of 3 (#1, #2, #3) patient medical records reviewed.

Findings:

Review of the hospital's policy titled "PC-1502: Restraints and Seclusion Use" revised 03/18/2024, revealed in part, "(G) When restraint or seclusion is used, there must be documentation in the patient's medical record of the following: c. Alternatives or other less restrictive interventions attempted (as applicable)"

Review of Patient #3's medical record revealed an admission date of 11/07/2024. Further review of the record revealed restraints were initiated on 11/24/2024 at 6:15 p.m. and discontinued at 8:15 p.m. Review of the restraint documentation failed to reveal documentation of less restrictive interventions implemented/attempted.

In an interview on 12/17/2024 at 1:01 p.m. S3CD verified there was no documentation of less restrictive interventions implemented/attempted prior to placing Patient #3 in restraints on 11/24/2024 at 6:15 p.m.

Based on record reviews and interview, the hospital failed to ensure all nursing staff received training and demonstrated competency for the use of restraints and seclusion. This deficient practice was evidenced by no documentation of competencies for the use of restraints and seclusion for 3 (S5RN, S6RN, S7RN) of 6 (S5RN, S6RN, S7RN, S8MHT, S9MHT, S10MHT) personnel records reviewed for training and competencies for the use of restraints and seclusion.

Findings:

Review of the hospital's policy titled "Restraints and Seclusion Use" revised 03/18/2024, revealed in part, "(D) Documentation will be maintained in staff personnel records that training and demonstration of competency were successfully completed."

Review of S5RN, S6RN, and S7RN's personnel records failed to reveal documentation of competencies for the use of restraints and seclusion.

In an interview on 12/17/2024 at 3:40 p.m. S1CEO verified there was no documentation of restraint and seclusion competencies included in S5RN, S6RN, and S7RN's personnel records.