Report Recommendations
for
The Community Hospitals
Anytown, Anywhere
August 17, 2007
__________________________________
Gary D. Slack, PE, CCE
Healthcare Engineering Consultants
Table of Contents
Subject
Page
Introduction
1-1
Recommendations for the Community East Behavioral Health Units
2-1
Recommendations for the Community West Behavioral Health Units
3-1
Recommendation Tracking Grid Summary
4-1
Appendix Documents
A – Behavioral Health Risk Assessment Forms and Information
5-1
Introduction
The purpose of this report is to provide specific recommendations to maximize the
safety of staff and behavioral health patients that are cared for at the Community East
and West Hospitals.
On August 10, an on-site consultation review with selected staff was conducted at the
Community East and West in Anyplace, Anywhere. The resulting recommendations
from these reviews are provided in sections 2 and 3 of this report.
Immediately following each recommendation, the Probability and Impact of each issue
that is presented is listed and the recommendation number (CE, Community East; CW,
Community West) is included and can be referenced with the summary chart in section
4. A “Discussion” section also provides additional explanatory information related to the
recommendation.
In section 4, a summary of the recommendations is provided in a color-coded grid sheet
for tracking and resolution purposes.
In the appendix, sample behavioral health risk assessment forms and information have
been included. In addition, electronic files of this report and the appendix information
are provided on the compact disk that is inserted at the front of this report binder.
1-1
Recommendations for the Community East
Behavioral Health Units
The following recommendations relate to each of the listed areas that were discussed
during the "on-site” review.
General Center
General Summary: Although it is intended that geriatric behavioral health patients who
are medically compromised and who pose minimum risk of injury to themselves and
others will be treated here, there is a trend to place higher acuity patients in this
environment. As a result, environmental issues in the General Center that may not
have initially been considered risk-averse may now create concern and unacceptable
risk in the unit.
Recommendation: Shorten the electrical cord and cable on the rear of the television
set that is in the dayroom area. Also, eliminate the ty-wraps that are used to bundle the
cables together. Medium Probability/ Medium Impact (CE-1)
Discussion: The presence of long electrical cords create a risk for patient self-injury and
can be easily removed from the rear of the television set. After the cords have been
shortened, the ty-wraps will no longer be necessary.
Recommendation: Consider the installation of tamper-resistant electrical receptacles in
all patient areas. Low Probability/ Medium Impact (CE-2)
Discussion: The National Electrical Code used to require the installation of tamperresistant electrical receptacles in all behavioral health areas, although that requirement
has recently been eliminated. An assessment by staff using the Behavioral Health Risk
Assessment Grid (BHRAG) to determine the impact of this change is recommended.
Recommendation: Shorten the electrical cord for the patient electrical beds from the
current length (approximately 5 feet) to 2 feet. Medium Probability/ Medium Impact
(CE-3)
Discussion: As noted previously, the presence of long electrical cords creates a risk for
patient self-injury. Be sure to maintain enough cord length so that the beds will still
easily plug into the electrical receptacle when in the proper headwall position and not
damage the strain relief or electrical receptacle.
2-1
Recommendation: Replace the metal wire that is currently used to hang the pictures in
the corridor with plastic clips. High Probability/ Medium Impact (CE-4)
Discussion: Un-insulated metallic wire can easily be used to create short circuits and
possible electrocution when plugged into electrical receptacles and can easily be
replaced with alternate, non-conductive materials. The existing wire length is also
sufficient to enable self-injury.
Recommendation: Consider the need to “fill in” the grab bars and cover the exposed
plumbing that is in the patient bathrooms. Low Probability/ Medium Impact (CE-5)
Discussion: An assessment by staff using the Behavioral Health Risk Assessment Grid
(BHRAG) to determine the impact of this change is recommended.
Recommendation: Replace the plastic liners with paper-type in the wastebaskets that
are in the patient areas. High Probability/ Medium Impact (CE-6)
Discussion: Plastic wastebasket liners or bags pose a patient suffocation opportunity.
Recommendation: Remove the flexible metal-sheath shower hose and replace with a
beveled shower head in the patient bathrooms. High Probability/ Medium Impact
(CE-7)
Discussion: The flexible shower hoses are long and can be easily removed by simply
twisting on the coupling. These hoses can be used for self-injury and in an area where
observation by staff is unlikely for moderate periods of time.
Recommendation: Perform a documented assessment using the Behavioral Health
Risk Assessment Grid (BHRAG) to determine the impact of replacing the existing
sprinkler heads with a tamper-resistant type. Low Probability/ Low Impact (CE-8)
Discussion: Although the existing sprinkler heads are not of the tamper-resistant type,
incident history suggests that they are not a problem.
Recommendation: Remove the nails from the cork board in the dining room and
replace with plastic hangars without sharp edges. High Probability/ Medium Impact
(CE-9)
Discussion: The nails can be easily removed by the patients and used as a weapon.
2-2
Recommendation: Cut the nurse call cords in the unit to no more than 12”. Medium
Probability/ Medium Impact (CE-10)
Discussion: The presence of long cords provides patients with the opportunity for selfinjury.
Recommendation: Replace the existing shower curtains with a “breakaway type”.
Medium Probability/ Medium Impact (CE-11)
Discussion: The existing shower curtains pose a risk of patient hanging in an
environment of temporary privacy.
Recommendation: Either install tamper-resistant screens on the patient room
windows, or provide tamper-resistant hardware to the existing latch assembly to prevent
the existing windows from fully opening. Medium Probability/ High Impact (CE-12)
Discussion: The existing window assembly has latch hardware with a Philips screw that
can easily be removed, permitting the window to be fully opened, so that a patient may
exit. The distance from a patient room on the third floor to the sub-level concrete below
May exceed 50 feet.
PICU Unit
General Summary: This 8-bed unit houses high acuity patients with a high staffing
level and includes provisions for patient seclusion and restraint. Because of this
environment, many steps to eliminate injury to patients and staff, such as using nonelectric beds, filling bathroom grab bars and concealing plumbing fixtures, have already
been incorporated.
Recommendation: Replace the current closer on the bathroom door with a springloaded type on the hinges that does not provide a support bar at the top of the door.
Also, replace the existing door knob with a flat handle. Medium Probability/ High
Impact (CE-13)
Discussion: These changes will eliminate the possibility of patient self-injury in a semiprivate environment.
Recommendation: Replace the existing bathroom ventilation vent with a tamperresistant grille or screen. Low Probability/ Medium Impact (CE-14)
2-3
Discussion: The existing vent poses a minor risk to patients.
Recommendation: Remove the fire alarm abort button in the nurses station. Low
Probability/ Low Impact (CE-15)
Discussion: The abort button has been disconnected, although unit staff could assume
incorrectly that it still functions.
Recommendation: Eliminate the use of unsecured compressed gas oxygen cylinders
in the unit. High Probability/ High Impact (CE-16)
Discussion: Consider the use of oxygen concentrators with patients, or secure the
compressed gas cylinders to beds during use, or discharge and transfer to a higher risk
hospital the patients requiring oxygen.
Acute Unit
General Summary: This 16-bed unit for dual-diagnosis, higher functioning patients, is
also representative of the 2 West unit and the recommendations provided below also
apply to the 2 West unit.
Recommendation: Eliminate the bathroom toilet roll assembly and replace with a
single piece “indent” in the wall. Medium Probability/ Medium Impact (CE-17)
Discussion: The toilet tissue holder can be used as a weapon by patients.
Recommendation: Replace the plastic bags in the dining area with paper bags. High
Probability/ Medium Impact (CE-18)
Discussion: Although food products are often placed in the bags, the use of paper is still
recommended. If necessary, limit the plastic bags to one container near the dining area
that is always in full view by the staff.
Recommendation: Consider turning on the piped oxygen in rooms 122 and 123 for use
with patients who require a nasal cannula, rather than using compressed gas cylinders.
Medium Probability/ Medium Impact (CE-19)
Discussion: The oxygen is currently turned off to these rooms, although the use of piped
2-4
oxygen is significantly less risky to patients and staff than the use of unsecured
compressed gas cylinders in behavioral health areas.
2-5
Recommendations for the Community West
Behavioral Health Units
The following recommendations relate to each of the listed areas that were discussed
during the "on-site” review.
PICU Unit
General Summary: This 8-bed unit houses high acuity patients with a moderate
staffing level and includes provisions for patient seclusion and restraint. Because of this
environment, many steps to eliminate injury to patients and staff, such as filling
bathroom grab bars and installing angled door hinges, have already been incorporated.
Recommendation: Provide additional training for unit staff regarding use of the proper
key to open the fire extinguisher cabinet and activate the fire alarm. Medium
Probability/ High Impact (CW-1)
Discussion: During the review, some staff were unable to locate and use the key to
open the fire extinguisher cabinet. Note: The Joint Commission surveyors will typically
request that staff in behavioral health areas demonstrate the use of their fire keys during
the tracer review.
Recommendation: Consider the installation of a recessed, tamper-resistant sprinkler
head in the patient seclusion room. High Probability/ Medium Impact (CW-2)
Discussion: These heads will minimize tampering and possible discharge, since they
would not be visible to the patients in the seclusion unit.
Recommendation: Hard-wire the electrical cords for the washer (120 volts) and dryer
(240 volts) to eliminate access to the receptacles. Medium Probability/ High Impact
(CW-3)
Discussion: Even though patients are supposed to be accompanied at all times by staff
when using the washer and dryer, access to the 240 volt plug and receptacle should be
eliminated.
Recommendation: Consider replacing the faucet fixtures for the bathroom sinks with
an ultrasonically activated unit that has a sloped discharge spout. Medium Probability/
High Impact (CW-4)
3-1
Discussion: This recommendation deserves extra attention, since there is a sentinel
event history associated with the existing fixtures. An ultrasonic unit will eliminate the
faucets and the use of a sloped spout for the water will minimize the possibility of
supporting a line, cord or clothing material. Refer to Appendix A for manufacturers and
distributors of ultrasonic faucet products.
Recommendation: Move the camera angle in the patient rooms so that observation of
a corner of the bathroom near the entrance door is possible. Medium Probability/
Medium Impact (CW-5)
Discussion: The current camera position does not permit viewing of any area of the
bathroom; re-positioning of the camera will provide a better view without compromising
patient privacy.
Recommendation: Review the current policy of permitting visitors to provide patients
with food products that are “sealed” and in their original packaging. Medium
Probability/ Medium Impact (CW-6)
Discussion: Although sealed packages may appear to be untampered, they provide an
opportunity for visitors to provide contraband to patients, such as illegal drugs, tobacco
products, matches and lighters, since they can be easily opened and resealed.
Recommendation: Remove the chains that have been attached to the shower curtains
in the patient bathrooms and replace with “breakaway” types that are non-metallic. High
Probability/ High Impact (CW-7)
Discussion: The existing chains can be easily removed and used for self-injury in a
patient privacy area.
Recommendation: Utilize a system to secure compressed oxygen cylinders to the
patient beds when they are in use or transfer patients who require oxygen to another
unit in the hospital or another hospital. High Probability / High Impact (CW-8)
Discussion: The use of unsecured compressed gas oxygen cylinders with behavioral
health patients is not recommended. Since this unit does not have electrical receptacles
provided in patient rooms, compressed gas cylinders should only be used when they
are secured. In areas where electrical outlets are available, the use of oxygen
concentrators should be considered.
3-2
Recommendation: Perform a documented risk assessment to determine when it is
appropriate to leave the nurses station door unlocked. Medium Probability/ Medium
Impact (CW-9)
Discussion: General guidelines that specify when the nurses station door can be
unlocked should be determined.
Recommendation: Eliminate the bathroom toilet roll assembly in the common
bathroom and replace with a single piece “indent” in the wall. Medium Probability/
Medium Impact (CW-10)
Discussion: The toilet tissue holder can be used as a weapon by patients.
Recommendation: Replace the other half of the common bathroom ceiling area with
sheetrock. Low Probability/ Medium Impact (CW-11)
Discussion: Half of the bathroom ceiling is sheetrock and the other half is of the “dropin” type. Installing a “hard” ceiling throughout will permit easier cleaning and minimize
the chance that patients could remove the ceiling tiles.
Additional Note: The door to room #106 does not latch properly and requires repair.
Adult Unit
General Summary: This 23-bed unit houses lower acuity patients than the PICU and
maintains a moderate staffing level. It is similar in function and patients served to Unit 1
at Community East.
Recommendation: Perform a documented risk assessment to determine which
patients are permitted to use the electric beds in the unit. Low Probability/ Medium
Impact (CW-12)
Discussion: If this procedure is already written, disregard the recommendations.
Recommendation: Install a closer on the door to the staff/ visitor bathroom near the
entrance to the unit, so that it automatically locks after use. Medium Probability/ High
Impact (CW-13)
3-3
Discussion: During the unit evaluation, the door to the visitors bathroom was open and
could be used by patients, even though they are instructed not to use it. Because the
bathroom is not equipped for behavioral patient use, it should be kept locked at all
times.
Recommendation: Install “breakaway” curtains in both of the common patient
bathrooms off of the central corridor. High Probability/ Medium Impact (CW-14)
Discussion: The existing shower curtains have hooks that can be easily removed and
used as weapons by patients.
Recommendation: Hard-wire the electrical cords for the washer (120 volts) and dryer
(240 volts) to eliminate access to the receptacles. Medium Probability/ High Impact
(CW-15)
Discussion: Even though patients are supposed to be accompanied at all times by staff
when using the washer and dryer, access to the 240 volt plug and receptacle should be
eliminated.
Recommendation: Replace the plastic bags in the patient dayroom area with paper
bags. High Probability/ Medium Impact (CW-16)
Discussion: Although food products are often placed in the bags, the use of paper is still
recommended. If necessary, limit the plastic bags to one container that is always in full
view by the staff.
Recommendation: Install additional cameras so that surveillance is possible for the
laundry and exam room corridors. Medium Probability/ Medium Impact (CW-17)
Discussion: Since camera surveillance is provided for the other common patient areas,
serious consideration should be given to providing visual surveillance to all common
patient areas.
Recommendation: Eliminate the bathroom toilet roll assembly in the common
bathroom and replace with a single piece “indent” in the wall. Medium Probability/
Medium Impact (CW-18)
Discussion: The toilet tissue holder can be used as a weapon by patients.
3-4
Recommendation: Create a written policy for the use of the tub room. Low
Probability/ Low Impact (CW-19)
Discussion: Since the tub room is not currently used for the original purpose, it should
either be removed or a policy for use should be created.
Recommendation: Eliminate the use of unsecured compressed gas oxygen cylinders
in the unit. High Probability/ High Impact (CW-20)
Discussion: Consider the use of oxygen concentrators with patients, or secure the
compressed gas cylinders to beds during use, or discharge and transfer to a higher risk
hospital the patients requiring oxygen. Note: During the unit tour, compressed gas “H”
cylinders were in use, which present a substantially larger potential safety problem than
the smaller “E” cylinders.
Recommendation: Perform a documented risk assessment to determine whether the
ceiling tiles in the egress corridors should have tamper-resistant clips installed. Low
Probability/ Medium Impact (CW-21)
Discussion: Ceiling tile clips have already been installed in the patient rooms.
Additional Note: Remove the paper sheets from the air supply vents in the patient
rooms. Either adjust the duct damper to decrease the air flow velocity or install the vent
upside down so that the air is deflected to the ceiling and not directly onto the patient
beds.
3-5
Recommendation Tracking Grid Summary
The tracking grid included in this section includes a summary of each of the
recommendations from the Community East (CE) and Community West (CW)
Behavioral Health Units. For each recommendation, the possible probability and impact
scores are listed, and the calculated risk score is provided in color, based on the
following chart:
Probability
Score (P)
Low (1)
Probability
Color
Impact
Score (I)
Low (1)
Impact
Color
Risk Score
(P X I)
1
Medium (2)
Low (1)
2
High (3)
Low (1)
3
Low (1)
Medium (2)
2
Medium (2)
Medium (2)
4
High (3)
Medium (2)
6
Low (1)
High (3)
3
Medium (2)
High (3)
6
High (3)
High (3)
9
Risk
Color
Notes:
1. The risk score for each recommendation is calculated as the numerical product of
the Probability Score (P) and Impact Score (I).
2. The associated risk color is determined from the following risk score scale:
Numerical Risk Score
1
2
3-5
6-8
9
Risk Color
3. The meaning of the risk colors is defined as follows:
4-1
Dark Green: Possible risk to patients or staff, but the issue should be evaluated for
possible action and the evaluation should be documented.
Light Green: Minimal risk to patients or staff, and the recommendation should be
implemented unless there are other clinical or environmental considerations.
Yellow: Moderate risk to patients or staff, and the recommendation should be
implemented when funds are available and after the completion of the orange and red
recommendations.
Orange: Serious risk to patients or staff and the recommendation should be completed
as soon as possible, after the red recommendations have been implemented.
Red: Extremely serious risk to patients or staff and the recommendations should be
implemented immediately.
4-2
Appendix A
Behavioral Health Risk Assessment Forms and Information
5-1