HospitalInspections.org

Based on observations made on 2/15/13, the Hospital failed to ensure that patient care areas were maintained for safe patient care. Buildings designated as locked inpatient psychiatric buildings were not locked for patient safety.

Findings include:

1) Observations made during the tour of the Locked inpatient unit, the Inn, on 2/15/13 at 12:30 P.M. demonstrated the entrance door to the Inn was unlocked and the two Surveyors entered the building. Patients were observed walking about. After approximately three minutes, the Day Nursing Supervisor came down the stairs and asked the Surveyors how they got into the building without a (sensor which unlocks a door). The Surveyors replied they simply turned the door knob and entered.

2) Observations made during a tour on 2/15/13 at 1:10 P.M. demonstrated that the door of the kitchen that lead outdoors to the trash was open. The Chef was interviewed on 2/15/13 at 1:10 P.M. The Chef said that the door was open and unlocked because he had just taken out the trash. When the Surveyor asked if he needed to lock the door while the tour continued, the Chef said no, he was right there (implying he was maintaining supervision) and proceeded to continue touring with the Surveyors. The Chef did not visually observe the open kitchen door at all times. The Inn is designated as a locked inpatient psychiatric faility.

3) Additional observations made during the tour of patient rooms on the ground floor demonstrated that windows opened approximately thirteen inches and the screens could be opened with free access to outside. The ability to open windows allowed for transfer or receipt of items.

4) During a tour of the Inn on 2/15/13 at 12:50 P.M., a light bulb fixture was observed to contain the remnants of a broken glass light bulb in the fixture with exposed light bulb filaments. The broken glass shards from the light bulb were observed on the floor in a secluded closet within a closet in patient room #6. The Surveyor obtained photos of the evidence.

Based on observations made on 2/15/13 during the tour of patient rooms at the Inn, a locked inpatient psychiatric building, the Hospital failed to ensure that preventative safety maintenance measures were made in the patient rooms.

1.) The Surveyors observed three unoccupied patient rooms (room #1, 6 and 15) during a tour at approximately 1:20 P.M. on 2/15/13:

A.) Observed in room #1 was a desk without a drawer. Also observed in room #1 was a dresser with a missing drawer and another drawer on the dresser was broken. Observations made in the closet of patient room #1 demonstrated a pipe with a torn insulating tube that was very hot to touch. The Surveyors touched the hot pipe and noted that a burn could occur with sustained contact.

B.) Observed in room #6 in the closet along the wall were exposed pipes without insulation.

C.) Observed in the floor of the closet in room #15 was an open, round hole approximately 3 inches by 3 inches. The dresser in room #15 was observed to have a bowed-out back panel with exposed nails.

2.) Observed in room #6, at 12:50 P.M. on 2/15/13, in the secluded closet within a closet was a light bulb fixture on the wall containing the screw cap with the remnants of broken glass with exposed light bulb filaments. Electrical current was still active in the room. The broken glass shards from the light bulb were observed on the floor. Photos of the evidence were obtained.