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An unannounced complaint survey was conducted for one intake per relevant sections of the State Operations Manual (SOM). Appendix A-Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals was utilized to determine the hospital's compliance with 42 CFR 482 Conditions of Participation (CoP) for Hospitals regarding:
Governing Body,
Patient Rights, and
Nursing Services.
An entrance conference was held on 6/17/2021 at 9:00 am with the Administrative Staff - Chief Nursing Officer (CNO), Administrator, Director of Quality Assurance/Risk Manager (QA/RM), and one of the managing partners. The purpose, scope, and process of the complaint survey was explained. A copy of instructions for writing an acceptable plan of correction was provided to CNO. An opportunity for questions and discussion was provided.
An exit conference was held on the afternoon of 6/22/2021 with the Administrative Staff - CNO, Director of QA/RM, and the Human Resources Manager. The preliminary findings were explained to the Administrative Staff and an opportunity was given for questions and discussion. The next steps in the survey process were explained. An opportunity was given for the facility to provide evidence of compliance with the requirements for which non-compliance had been found during the survey.
The exit conference date was extended to 7/5/2021, which provided additional time for the facility to produce more documentation.
During the investigation of Complaint Intake TX00385370, deficient practices were identified under the following Condition of Participation that were determined to pose an Immediate Jeopardy to patient health and safety, and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.
CFR 482.13 PATIENT RIGHTS
The facility was presented with two Immediate Jeopardy templates that informed the facility about the issues of noncompliance, the outcome, and likelihood of harm, as well as the need for immediate action to protect patients. Both Immediate Jeopardy templates were presented to the CNO on 6/18/2021 at 3:fpm. The facility was found to be out of compliance with the following Condition of Participation:
CFR 482.13 PATIENT RIGHTS
On 6/17-18/2021, the following observations were made:
a) 10 of 17 bedrooms had tie-off points between the headboard and the wall that created an observable ligature risk. There were 7 of 19 patients, admitted with suicidal ideation, assigned to one of the ten bedrooms with observable ligature risks. A suicidal patient could tie a knot in one corner of a piece of fabric, wedge the knot between the wall and the headboard, and hang self.
b) 1 of 17 bedrooms had 2 beds that were not bolted to the floor. There was 1 of 19 patients, admitted with suicidal ideation, assigned to that bedroom. The unbolted beds can be moved against the bedroom door, blocking entry into the bedroom from the hallway.
c) The PVC cover that enclosed the tankless plumbing system on 4 of 19 toilets created tie-off points. There were 3 of 19 patients, admitted with suicidal ideation, assigned to a bedroom that had toilets with a PVC cover that created a tie-off point.
d) 17 of 17 bedrooms had "live" electrical outlets. There were 19 of 19 patients placed in a bedroom with numerous "live" electrical outlets. "Live" electrical outlets can be a fire and safety hazard.
The first Immediate Jeopardy was based on findings a), b), and c). A second Immediate Jeopardy was identified based on findings d).
The CNO and Director of QA/RM were informed of the Immediate Jeopardies and were offered the opportunity to provide a plan of removal that would abate the likelihood of harm identified. On the evening of June 18, 2021, the CEO provided an acceptable plan of removal to abate the Immediate Jeopardies. This plan included:
1. Beds that were identified with tie-off points will be repositioned and bolted into place to remove all ligature access points - initiated 6/17/2021.
2. Toilets with tie-off points will have panels placed across the ligature access point to remove access.
3. Environmental round sheets will include observation of the toilet panel to be intact each shift. Staff will be educated on assessing the toilet panel.
4. New admissions will be placed in rooms that already have ligature resistant beds and toilets and beds that have been repositioned and bolted as they become available.
5. The electrical outlets will be covered with blank metal plates that will be mounted with tamper-proof screws beginning immediately.
6. Plant maintenance staff are on call 24/7 to change blank plate to a functional plate if a patient requires medical equipment that needs electricity.
7. Staff education regarding environment of care rounds to include increased awareness of electrical outlets.
The surveyor verified that the headboards were completed by 6/22/2021. Many of the electrical outlets were completed by 6/22/2021. There was a shortage of blank plates at retail outlets. New admissions with suicidal ideation had safe rooms in which to be admitted.
The following Conditions of Participation were found to be out of compliance:
CFR 482.12 GOVERNING BODY
CFR 482.13 PATIENT RIGHTS
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