Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 670093	(X3) Date Survey Completed 06/22/2021
Name of Provider or Supplier Aspire Hospital	Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0144

PATIENT RIGHTS: CARE IN SAFE SETTING
CFR(s): 482.13(c)(2)

The patient has the right to receive care in a safe setting.

This STANDARD is not met as evidenced by:
Based on interview, record review, and observation, the facility failed to ensure that patients received care in a safe setting. Specifically, A. The facility failed to ensure that 10 of 17 bedrooms (bedroom #100, 101, 103, 202, 204, 205, 206, 207, 208, and#209) were free of tie-off points between the headboard and the wall. This failure resulted in 7 of 19 patients (patient #1, 2, 13, 15, 17, 18, and#19), admitted with suicidal ideation, were assigned to one of the 10 bedrooms that had observable ligature risks. B. The facility failed to ensure that 1 of 17 bedrooms (bedroom #203) had 2 beds that were bolted to the floor. This failure resulted in 1 of 19 patients (patient #3), admitted with suicidal ideation, was assigned to bedroom 203. The unbolted beds can be moved against the bedroom door, blocking entry into the bedroom from the hallway. C. The facility failed to ensure that the PVC cover that enclosed the tankless plumbing system on 4 of 19 toilets was free of tie off points. This failure resulted in 3 of 19 patients (patient #1, #18, and #19), admitted with suicidal ideation, were assigned to one of the bedrooms that had toilets with a PVC cover that created a tie-off point. D. The facility failed to ensure that 17 of 17 bedrooms (bedroom #100, 101, 102, 103, 104, 105, 106, 107, 108, 202, 203, 204, 205, 206, 207, 208 and #209) had safe electrical outlets. This failure resulted in 19 of 19 patients (patients 1-19) being placed in a bedroom with numerous "live" electrical outlets. "Live" electrical outlets can be a fire and safety hazard. E. The facility failed to ensure that the "Environment of Care Safety Rounds" were completed each shift. This failure resulted in the following safety issues not documented: 10 of 17 bedrooms having ligature risks (tie-off points) in the bedrooms, 1 of 17 bedrooms with unbolted beds, 4 of 17 toilets with ligature risks (tie-off points), and 17 of 17 bedrooms with "live" electrical outlets. F. The facility failed to ensure that an environment of care risk assessment was conducted. This failure resulted in the following safety issues not documented: 10 of 17 bedrooms having ligature risks (tie-off points) in the bedrooms, 1 of 17 bedrooms with unbolted beds, 4 of 17 toilets with ligature risks (tie-off points), and 17 of 17 bedrooms with "live" electrical outlets. G. The facility failed to ensure that 1 of 1 suicidal patient (patient #20) in the Intake Department was monitored closely during the admission process by properly trained staff on the management of suicidal patients. The patient was placed alone in an ED bay with numerous pieces of equipment that could be used for hanging or strangulation. H. The facility failed to ensure that the wall-mounted TV in the commons area on the back hallway was free of exposed electrical wiring and tie off points that could be used for hanging or strangulation. I. The facility failed to ensure that the seclusion room bathroom was a safe environment as evidenced by a lightweight two-drawer wooden cabinet on wheels, a lightweight chair, and a trash receptacle with a plastic bag liner in the space. The cabinet and chair can be used as a weapon. The plastic bag can used for suffocation. In addition, there were no video surveillance cameras in the seclusion anteroom. J. The facility failed to ensure that stored oxygen cylinders were secured with a rack or chains to prevent tipping, falling, or rolling. Should the cylinder fall over, it might break, causing the pressurized oxygen to escape rapidly. This pressure can cause the tank to fly through the air. Findings included: A, B, C - ligature risks. During a tour on June 17, 2021 at 10:00 am with Staff A (CNO) and Staff B (Director of Quality), the following interviews was conducted, and the following items were observed: 1) 7 beds, bolted to the floor, created a gap between the headboard and the wall. These 7 beds were found in the following rooms: room #100, 101, 202, 203, 204, 205, and #206. Staff A removed a flat sheet from a patient's bed, tied a knot in one corner of the bedsheet, and wedged the knot between the headboard and the wall. He pulled on the bedsheet; the knot stayed wedged in the gap. He stated that the space between headboard and the wall created a tie-off point that could be used for the purpose of hanging. He further stated he did not know that there was a gap between the headboard and the wall in these bedrooms that could be used as an anchor point for hanging. 2) 2 beds were not bolted to the floor in room #103. Staff A stated that the top of the bedroom door could be used as a tie-off point. He also stated that the beds could be repositioned in such a way as to prevent staff from being able to get into the bedroom. He further stated, he did not know that there were beds that were not bolted to the floor. 3) Access to the tankless plumbing system of all 17 toilets had been altered with the installation of a white PVC cover. There were two one-inch holes in each cover, one on top of the toilet that provided access to a button that could be pushed to flush the toilet and one on the front of the cover that exposed the no touch sensor. The hole for the no touch sensor had been covered with a rectangular piece of clear plastic. The clear plastic rectangle had come off four toilets (room #101, 207, 208, and #209). A tie-off point was created by running a corner of a sheet through one hole and then the other. Staff A was reminded that the toilets had been cited in a previous survey for this ligature risk. He stated that it appeared the clear plastic rectangle had come off the four toilets in question. He pointed to sticky strips that had held the clear plastic rectangle in place over the hole. He also stated the two holes created a tie-off point. He further stated he did not know that there were anchor points on four of the patient toilets. Record review of the Final Census Report, dated June 17, 2021 at midnight, showed a census of 19 patients. Each patient had been assigned to a room (rooms 100-108 and 202-208) and a bed number. The report showed the following 8 patient placements: Patient #1 - Room 100 Patient #2 - Room 101 Patient #3 - Room 102 Patient #13 - Room 202 Patient #15 - Room 204 Patient #17 - Room 206 Patient #18 - Room 207 Patient #19 - Room 208 Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "Patients will be assessed for suicide risk ... Staff responsible for monitoring patients on suicide precautions will maintain the patient in a safe environment and take measures to protect the patient from self-harm or self-injurious behavior ... " The 8 patients with suicidal ideation placed in a bedroom with a ligature risk. Patient #1 Room 100 - gap between headboard and wall, and anchor point on toilet. Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/10/2021 at 10:4, showed Patient #1 was an involuntary 60-year old male complaining of suicidal thoughts. He stated, he had a plan to shoot himself and die. His speech was pressured and rapid with flight of ideas. Insight and judgement were poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/10/2021 at 10:4, showed that Patient #1 had a preliminary diagnosis of Bipolar I disorder, mixed, severe. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff D (MD), dated 6/11/2021 at 9:12 am, showed that Patient #1 had a long history of depression and bipolar disorder, complicated by cancer and chronic pain which led to drug dependence. He had a previous history of suicide attempt. He was delusional and his mood was volatile. Insight and judgement were impaired. Patient #2 Room 102 - gap between headboard and wall. Record review of the Pre-admission Evaluation by Staff E (MD), dated 5/14/2021 at 5:5, showed that Patient #2 was an involuntary 40- year old female complaining of suicidal thoughts. She stated, she wanted to "take a bunch of pills." She was delusional, confused, and rambling. Her insight and judgement were poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 5/14/2021 at 5:5, showed that Patient #2 had a preliminary diagnosis of delusional disorder. Orders: Admit to the inpatient psychiatric unit, suicide and elopement precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff D (MD), dated 5/15/2021 at 2:3, showed that Patient #2 had depressed mood, religious delusions, auditory hallucinations ("talking to God"), and threats of suicide. Insight and judgement were impaired. Patient #3 Room 103 - beds not bolted to the floor. Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/11/2021 at 11:09 am, showed that Patient #3 was a voluntary 23-year old female complaining of suicidal thoughts. Insight and judgement poor. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/11/2021 at 11:09 am, showed that Patient #3 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff H (MD), dated 6/12/2021 at 12:2, showed that Patient #3 had depressed mood, mood swings, anger, and a "very tumultuous past including multiple sexual assaults and abuse." She had been engaged in cutting behavior in teenage years. History of methamphetamine use. Patient #13 Room 202 - gap between headboard and wall. Record review of the Pre-admission Evaluation by Staff F (MD), dated 6/11/2021 at 5:3, showed that Patient #13 was a voluntary 36-year old female complaining of suicidal thoughts with a plan to overdose. Her insight and judgement were fair. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff F (MD), dated 6/11/2021 at 5:3, showed Patient #14 had a preliminary diagnosis of major depressive disorder, recurrent, severe and generalized anxiety disorder. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff H (MD), dated 6/12/2021 at 11:30 am, showed that Patient #14 was suicidal with a plan to cut her wrist or overdose. Threatening suicide. History of cutting her inner thigh (2020). Patient #15 Room 204 - gap between headboard and wall. Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/12/2021 at 8:6, showed that Patient #15 was a voluntary 51-year old male complaining of suicidal thoughts. He was tearful and not wanting to live. His pain level was 10 on a scale of 0-10. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/12/2021 at 8:6, showed that Patient #15 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide and seizure precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff H (MD), dated 6/13/2021 at 10:11 am, showed that Patient #15 was delusional, hyperverbal, and manic. He had no insight and very poor judgement. He was threatening suicide. Patient #17 Room 206 - gap between headboard and wall. Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/9/2021 at 12:5, showed that Patient #17 was an involuntary 19-year old female complaining of suicidal thoughts with intent. She was picked up by her parents from a motel known for heavy drug use. She tried to open the car door while the car was moving down a freeway. She told her parents they "should have left me there to die. If it's my time, it's my time." She had a history of cutting and use of street drugs. There was a history of borderline personality disorder. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/9/2021 at 12:5, showed that Patient #17 had a preliminary diagnosis of major depressive disorder, recurrent, severe. Orders: Admit to the inpatient psychiatric unit, suicide and elopement precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff D (MD), dated 6/10/2021 at 10:11 am, showed Patient that #17 was recently jailed, with chemical dependency issues. Her mood was manic and volatile. She had paranoid and grandiose delusions and a previous suicide attempt. She had poor insight and impaired judgement. Diagnosis was changed to bipolar I disorder, moderate, manic. Patient #18 Room 207 - anchor point on toilet. Record review of the Pre-admission Evaluation by Staff E (MD), dated 6/13/2021 at 10:1, showed that Patient #18 was a voluntary 43-year old male with suicidal thoughts and auditory hallucinations. He had a history of paranoid schizophrenia. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff E (MD), dated 6/13/2021 at 10:1, showed that Patient #18 had a preliminary diagnosis of schizophrenia, disorganized type. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff D (MD), dated 6/14/2021 at 10:32 am, showed that Patient #18 had chemical dependency issues and a previous suicide attempt. Insight and judgement were impaired. Patient #19 Room 208 - anchor point on toilet. Record review of the Pre-admission Evaluation by Staff C (MD), dated 6/13/2021 at 9:9, showed that Patient #19 was a voluntary 56-year old male complaining of suicidal thoughts. He also verbalized homicidal intent toward female. He talked of stepping in front of traffic. He was verbally aggressive. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of Physician's ... Orders and Preliminary Plan of Care by Staff C (MD), dated 6/13/2021 at 9:9, showed that Patient #19 had a preliminary diagnosis of bipolar I disorder, depressed, severe, with psychotic features. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Record review of Psychiatric Evaluation by Staff D (MD), dated 6/14/2021 at 3:2, showed that Patient #19 had severe depression and thoughts of dying. Insight and judgement impaired. Diagnosis changed to bipolar I disorder, depressed, recurrent, severe, without psychosis, and substance use, misuse, abuse (cocaine, severe). D - Patients in rooms with "live" electrical outlets. During a tour on June 17, 2021, at 10:00 am, with Staff A (CNO) and Staff B (Director of Quality), the following interviews were conducted, and observations were made. Staff B (Director of Quality) was observed testing one or two outlets in each of the 17 bedrooms with her phone charger. She stated all outlets were "live." There were 19 of 19 patients (patients 1-19) in the bedrooms with "live" electrical outlets. Staff A (CNO) stated that the electrical outlets should not be "live" because of potential fire and safety hazard. He further stated, he did not know that the electrical outlets were "live." Record review of the Registration Admission form showed the following: Patient #1 admitted 6/11/2021 at 12:02 am Patient #2 admitted 5/14/2021 at 6:4 Patient #3 admitted 6/11/2021 at 11:28 am Patient #4 admitted 6/11/2021 at 5:21 pm Patient #5 admitted 6/11/2021 at 5:22 pm Patient #6 admitted 6/8/2021 at 12:03 pm Patient #7 admitted 6/8/2021 at 4:36 pm Patient #8 admitted 6/11/2021 at 8:59 pm Patient #9 admitted 6/16/2021 at 2:19 pm Patient #10 admitted 6/1/2021 at 8:29 am Patient #11 admitted 6/13/2021 at 5:27 pm Patient #12 admitted 6/9/2021 at 5:15 pm Patient #13 admitted 6/11/2021 at 5:57 pm Patient #14 admitted 6/5/2021 at 1:05 pm Patient #15 admitted 6/12/2021 at 7:42 pm Patient #16 admitted 6/14/2021 at 11:42 pm Patient #17 admitted 6/9/2021 at 12:38 pm Patient #18 admitted 6/13/2021 at 10:11 pm Patient #19 admitted 6/13/2021 at 10:55 pm Record review of the Final Census Report, dated June 17, 2021 at midnight, showed a census of 19 patients. Each patient had been assigned to a room (rooms 100-108 and 202-208) and a bed number. The report showed the following 19 patient placements: Patient #1 - Room 100 Patient #2 - Room 101 Patient #3 - Room 102 Patient #4 - Room 103 Patient #5 - Room 104 Patient #6 - Room 105 Patient #7 - Room 105 Patient #8 - Room 105 Patient #9 - Room 106 Patient #10 - Room 107 Patient #11 - Room 108 Patient #12 - Room 108 Patient #13 - Room 202 Patient #14 - Room 203 Patient #15 - Room 204 Patient #16 - Room 205 Patient #17 - Room 206 Patient #18 - Room 207 Patient #19 - Room 208 E - Environment of Care Safety Rounds Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "The environmental safety checks are conducted regularly to identify and minimize any environmental risks." In an interview with Staff A (CNO) and Staff P (Unit RN) on 6/21/2021 at 1:00 pm, Staff A provided a blank copy of a "Daily Environmental Rounds Report" and stated the form was to be completed during the change of shift by the oncoming RN and the off-going MHT. Only one completed Environmental Rounds Reports was provided to the surveyor by Staff P. Staff A stated, the "Daily Environmental Rounds Report" needed to be revised. Record review the "Daily Environmental Rounds Report" dated 6/21/2021 for the 7A to 7P shift showed the following areas were assessed by Staff P (Unit RN): Nurses Station - no food/drinks; Storage Rooms; Tub/Shower Rooms; Psych Consult Room; Exam Room; Laundry Room; Medical Equipment Storage; Seclusion Room; Patient Rooms - no contraband found, no patient hazards or ligature risks, damage to room observed, infection control issues observed; Recreation Therapy; Maintenance Issues - shower on the 100 hall is weak; window tint needs to be fixed in rooms 104, 105, and 203. A work order for the window tint was made. NOTE: The Daily Environmental Rounds Report does not specify checking the patient bathrooms. F - Environment of care risk assessment During an interview with Staff A (CNO) and Staff B (Director of Quality) on June 17, 2021, at 10:00 am he stated that the facility did not have an environmental risk assessment. He further stated that an environmental risk assessment was an assessment, updated periodically, that documented all environmental risks throughout the facility. He concluded by stating that the environment risk assessment should also include mitigation strategies for those risks that could not be corrected or removed. Record review of the policy EC.001, "Environment of Care Safety Rounds," revised 12/12/2020, showed: "It is the policy of the Inpatient Behavioral Health Service to have a safe, functional and supportive environment for patients and staff. A systematic approach will be operational to proactively identify and manage environment risks and minimize the harm or risk to patients or others. Staff will actively participate in this approach by identifying and reducing environmental risks. PROCEDURE 1.0 Environment of Care Safety rounds will be conducted by assigned staff every 12-hour shift and documented on checklist. The assignment will be performed by the Charge RN and a witness. 2.0 All patient rooms, common areas, and hallways are checked for ligature risks, non-tamper resistant screws, and any other environment of care hazards as well as contraband ... 3.0 4.0 5.0 Quarterly, a proactive environment of care risk assessment is conducted with Behavioral Health leadership as well as the Risk Manager and Safety Officer. A corrective action plan is developed based on the findings of the annual proactive EOC risk assessment. The quarterly EOC assessment and corrective action plan is submitted to ... QIC Committee." G - Suicidal patient not monitored in the Intake Department. Record review of Policy PC.003A, "Patient Awaiting Full Assessment in Lobby," revised 12/30/2019, showed: "[The facility] strives to provide patient care within a safe environment." The policy further states that if a patient is found to be highly suicidal, "a 1:1 for the individual will be arranged until the full assessment can be done." Record review of Policy PC.013, "Suicide Risk Assessment and Precautions," revised 12/30/2019, showed: "Patients will be assessed for suicide risk ... Patients assessed to be at heightened risk of suicide or self-injurious behaviors will be placed on suicide precautions commensurate with the assessed level of risk ... Staff responsible for monitoring patients on suicide precautions will maintain the patient in a safe environment and take measures to protect the patient from self-harm or self-injurious behavior ... 15.0 Upon initiation of suicide precautions, ... items that could pose a ligature risk or harm to patient are prohibited ... 19.0 The environmental safety checks are conducted regularly to identify and minimize any environmental risks. 20.0. All new employees responsible for patient care will receive orientation regarding Management of Suicidal Patients. All staff will successfully complete the Suicide Prevention competency annually." Observation on 6/21/2021 at 11:35 am showed, Patient #20 was sitting on a bed in a bay of the "future" emergency department. The ED bay had 4-IV infusion pumps on poles with electrical cords, EKG machine with leads and an electrical cord, and a vital sign monitor with an electrical cord and blood pressure cord. There were numerous cords connected to the wall at the head of the bed. The bed had numerous tie-off points. There was a cotton sheet on the mattress. Two staff members were in the admission office: Staff I (Intake RN) and Staff J (Intake Coordinator). There was an ED bay between the admission office and the ED bay Patient #20 was sitting in. There were no other patients in the Intake Department awaiting assessment. There were no other patients in the lobby of the Intake Department awaiting assessment. In an interview with Patient #20 on 6/21/2021 at 11:35 am, she stated that she had been seen by the nurse and was waiting to be evaluated by a physician. Record review of the Medical Screening Exam for Patient #20, dated 6/21/2021 [not timed], by Staff I (Intake RN), showed: "A medical screening exam has been completed and an emergent medical condition does exist." The Columbia Suicide Severity Rating Scale Screen with Triage Points for Primary Care (C-SSRS) for Patient #20 showed that she answered "Yes" to the following two questions: Have you wished you were dead or wished you could go to sleep and not wake up? Have you had any actual thoughts of killing yourself? The admission Columbia score was 2, which indicated routine Q15 minute observations. In an interview with Staff I (Intake RN) on 6/21/2021 at 11:37 am, she stated that she was the Intake RN on duty. She also stated, she had completed a suicide assessment on Patient #20 and was awaiting the tele-med assessment by a psychiatrist. She also stated a suicidal patient was not supposed to be in the ED bay alone, adding that she did not know the patient did not have someone with her. She also stated that the patient was waiting to be evaluated by a tele-med psychiatrist. She concluded by saying the patient was supposed to have a sitter with her. In an interview with Staff J on 6/21/2021 at 11:38 am, she stated that she was the Intake Coordinator on duty. She also stated that Patient #20 was not supposed to be in the ED bay alone, adding that she too did not know the patient did not have someone with her. In an interview with Staff A (CNO) on 6/21/2021 at 11:39 am, he stated that patients in the ED are supposed to be monitored and not left alone. Record review of the HR personnel file for Staff I (Intake RN) showed no documentation of orientation regarding Management of Suicidal Patients or annual training on Suicide Prevention. Record review of the Human Resources personnel file for Staff I (Intake RN) showed no job description for the Intake RN. There was no evidence of training on monitoring of patients on suicide precautions. In an interview with Staff U (HR Director) on 7/1/2021 at 9:45 am, she stated that she had no other documentation in the personnel file for Staff I (Intake RN) other than what she had provided. On the following day, 6/22/2021, the Pre-admission Evaluation, dated 6/21/2021 at 12:04 pm, by Staff F (tele-med MD) was reviewed. The evaluation showed that Patient #20 was a voluntary 46-year old female with complaints of depression. She had suicidal thoughts. She felt like she was just existing and could not find joy in life. She stated, she had a previous suicide attempt by overdose in 2007. She had been hearing voices "judging her" and felt like people were talking about her. She went without sleep for 2 days, two weeks earlier. She had thoughts of wanting to die. She had been isolating and felt hopeless. It was further documented that the patient had a "current or potential threat to self, others, or property due to active manifestations of the psychiatric disorder, which warrants a controlled environment for continuous skilled observation, evaluation, and care, as is only available for the level of care chosen." Record review of the Physician's Pre-admission Examination Orders dated 6/21/2021 at 12:04 pm by Staff F (tele-med MD), showed a preliminary diagnosis of major depressive disorder, recurrent, with psychotic features. Orders: Admit to the inpatient psychiatric unit, suicide precautions, and Q15 minute observations. Staff I (Intake RN) signed off on the orders on 6/21/2021 at 12:24 pm. H - Wall-mounted TV During a tour of the unit on 6/22/2021 at 1:00 pm, it was observed that there were four hallways on the unit - two long hallways and two short hallways. Patient bedrooms were on the outside of the two long hallways. On one of the short hallways was the nurse's station. On the other short hallway was the common's area. In the commons area (on the back hallway) was a wall-mounted TV. The TV had not been enclosed, thus, exposing electrical and cable wires. The wall-mount hardware created tie off points that could be used for hanging or strangulation. In an interview with Staff A (CNO) on 6/22/2021 at 1:00 pm, he stated that the wall-mounted TV should be enclosed to prevent patient access to the electrical and cable wires and tie off points created by the wall-mount hardware. I - Seclusion room bathroom. During a tour of the unit on 6/17/2021 at 10:00 am, the seclusion room bathroom was observed to have a lightweight two-drawer wooden cabinet on wheels in the corner adjacent to the toilet. There was also a lightweight chair in the doorway to the bathroom. The liner in the trash receptacle was a plastic bag. In an interview with Staff A (CNO) on 6/17/2021 at 10:00 am, he stated that the lightweight cabinet and chair could be used as a weapon, and the plastic bag can be used for suffocation. He also stated these objects should not be in the seclusion room bathroom. In an interview with Staff N (CNA) on 6/17/2021 at 11:25 am, she stated that the rolling cabinet should not be in the seclusion room bathroom because it could be used as a "weapon." Staff N also stated that a staff member will stay in the seclusion room area if a patient is in the quiet room. She concluded by saying that there were no video surveillance cameras in the seclusion area, adding, "there needs to be." In an interview with Staff O (MHT) pm 6/17/2021 at 11:45 am, she stated that when a patient is in the quiet room, a "someone is there." J - Oxygen cylinder. Observation of the Medical Equipment Room on 6/17/2021 at 12:30 pm showed four oxygen cylinders were unsecured. In an interview with Staff A (CNO) on 6/17/2021 at 12:30 pm, he stated that the oxygen cylinders are supposed to be secured with a stable base. Record review of the National Fire Protection Association (NFPA) Standards 99 Health Care Facilities (2005 edition, updated 2017) showed that oxygen cylinders are to be secured with a rack or chain.