HospitalInspections.org

The Standard is not met as evidenced by:

Based on interview, observation and document review, it was determined that the respondent facility failed to meet all requirements of the Condition of Participation: Patient's Rights. The respondent facility's failure to do so placed patients at risk to self-harm.

Findings include:

1) On January 26, 2014 the staff found Patient #1 hanging from the door closure hardware in a shower room with a bed sheet around his/her neck.
2) The patient was assessed at intervals according to policy and procedure. On day 26 of admission, the patient expressed suicide ideations and was placed on constant suicide watch for 8 days. The patient was then assessed as " not a danger to self or others " and therefore did not require suicide observation orders. The staff performed environmental rounds on all patients every 30 minutes as validated by the rounding log sheets. The patient was on privileges to shower. There are specific hours the shower room is open and patients must sign up to schedule the shower room. This policy was followed.
3) Following a 2012 incident, the hospital identified a list of hardware (i.e. plumbing, door handles, and door closures) that posed a potential risk to patients. The hospital, through committee, identified priorities and provided each unit with two ' safe rooms '. These identified rooms had the potentially harmful hardware removed or replaced. These ' safe rooms ' modifications were completed in 2013. The hospital then prioritized the remainder of the necessary changes based on capital funding availability. At the time of this investigation, the hardware was not replaced in total.
4) On February 14, 2014, the Chief Operating Officer met with the leadership team responsible for resource allocation to continue the replacement of hardware. The Secretary of the Department of Social and Health Services emergently approved resources to assess the necessary requirements to eliminate the potentially harmful hardware. The assessment phase is to be completed within 6-8 months. However, no timeline on the completion of removing the hardware was included.
5) Patient #1 was assessed not to be at harm to self or others and therefore was not on suicide observation. All patients are included in the Environmental and Safety rounds that take place every 30 minutes. The medical record indicates the rounding was completed per policy. The facility made an immediate policy change to increase the safety rounds to every 15 minutes. This change was validated on review of seven current patient records.