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Based on surveyor observation and staff interviews, it was determined that the hospital failed to ensure that the physical condition of the psychiatric units in the Adolph Myer (AM) building were maintained in a manner to ensure the safety and well being of patients.

Findings are as follows:

A review of the clinical record for patient ID # 1 revealed an admission to the hospital in 2004 with a borderline personality disorder. The patient has a long history of self-injurious behaviors (SIB) that includes cutting, jumping out of moving automobiles, attempted strangulation, head banging, and breaking fingers. A 1:1 continuous observation has been required for patient safety. It was noted that the last patient incident of SIB was 2/4/11. The patient's Behavioral Plan focused on self awareness, and "spotlighting interpersonal skills to begin to relearn boundaries of acceptable behavior as it related to discharge readiness". The patient was included in this plan to allow opportunities for reinforcement to build self confidence in abilities to regain control. On 3/28/11, the plan was to discontinue 1:1 on the first shift only, and allow the patient a pass with a family member.

On 3/30/11, the patient went off the unit at 10:15 AM for a 4 hour pass with the family member. Upon return, the patient was noted to be very happy, and reported a good visit. On 3/31/11 at 1:35 PM, the nurse noted that the patient had been in a good mood, and had been socializing in the Dayroom with staff. It was also noted that the patient had participated that morning in the Day Program with the walking group. The patient had been compliant with medications and had taken lunch, and was then escorted to the Community Resource Area by an IAP (Institutional Attendant Psychiatric).

The patient was met there by the Director of Activities for an afternoon program. As they passed the Sensory Room, the patient requested to stop there instead of going to the Computer room to download CD's into a computer as planned. The Activities Director began to engage in conversation with the patient, when she was called away to direct a facility maintenance worker to a water leak from the ceiling in the Audio Visual Room about twenty feet away. When she returned to the Sensory Room, she found the door closed and locked. She unlocked the door with a master key that she carries, but had difficulty opening the door because a sofa from inside the room had been placed across the door. She pushed past the sofa to find the room empty with the security window screen and window wide open. When she looked out the window, she saw the patient on the ground and called for help. The patient was taken to the hospital, where she was treated for fractures of her femur, tibia, pelvis, sternum, and ribs.

During observation of the psychiatric units and the Community Resource Area, it was noted that windows have locked safety screens that are located in front of the windows. These safety screens can be unlocked to open or close the window, with a designated key left in a secured area. It is expected that the safety screen is securely locked after the window is opened or closed.

During an interview on 4/21/11 at 11:30 AM with the Adolph Myer Nurse Manager, she reported that the hospital has a policy in place for Unit Safety Checks on each shift. This includes that safety screens are locked. During a tour of the psychiatric units, all safety screens were noted to be locked, with evidence that Unit Safety Checks are being done every shift per the hospital protocol.

It was determined that the safety screen had not been locked in the Sensory Room after a staff person had opened that window, resulting in an unsecured window and the subsequent patient occurrence. It was also determined that although Unit Safety Checks are done on the Psychiatric Units, there was no formal policy/procedure in place in the Community Resource Area to ensure that the safety screens are locked in that patient area.

During a tour of the psychiatric units and patient care areas on 4/21/11 from 10:10 AM to 11:40 AM with the Nurse Manager, Director of APS (Adult Psychiatric Services), Safety Officer, and Administrator of Licensing, the following conditions were observed that pose hazards for patients at risk for harming themselves:

Psychiatric unit AM 4 has drop ceilings in the common areas, under the sink exposed plumbing in the bathroom of patient room 276, and a shower control with an on/off lever handle in the Shower Room.

Psychiatric unit AM 7 has "drop" ceiling tiles in the common areas and all patient rooms, standard round door knobs on all doors, and a lever type door handle on the exit door.

Psychiatric units AM 8, 10, 11 and 12 have "drop" ceiling tiles in the common areas, standard round door knobs on all doors, and a lever type door handle on the exit doors.

Psychiatric unit AM 9 has a wall mounted television with an approximate 16-18 inch unsecured electrical cord plugged into an electrical outlet, "drop" ceiling tiles in the common areas, and standard round door knobs on all doors.

The patient Cafeteria has "drop" ceiling tiles.

The Basement Canteen and Activity Room has exposed insulated hot water ceiling pipes. In addition, the Activity Room has a television mounted to the wall with an approximate 16-18 inch unsecured electrical cord plugged into an electrical outlet.

The Community Resource Area on the 4th floor has standard round door knobs on all doors, and "drop" ceiling tiles in the common areas and in the Library Room, Audio Visual Room, Exercise Room, and Computer Room. The bathroom across from the Library has exposed, under the sink, plumbing. The Shower Room has exposed, under the sink, plumbing. The Shower Room also has exposed plumbing on two toilets, and a shower control with an on/off lever handle. Radiators in the hallway, Exercise Room, Computer Room, and Library have exposed heating control valves.