Terrell State Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40989 Based on observation, document review, and interview, the facility failed to develop and implement an appropriate plan to keep patients safe in an environment with known, identified ligature risks in 3 (Unit 7A, Unit 7B, and the Geriatric Unit) of 3 units observed. Patients were allowed to be in areas of the Geriatric Unit, Unit 7A, and Unit 7B without staff supervision. This provided a patient with enough time to harm themselves without staff present to intervene. Refer to Tag 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: 40989 Based on observation, document review, and interview, the facility failed to develop and implement an appropriate plan to keep patients safe in an environment with known, identified ligature risks in 3 (Unit 7A, Unit 7B, and the Geriatric Unit) of 3 units observed. Patients were allowed to be in areas of the Geriatric Unit, Unit 7A, and Unit 7B without staff supervision. This provided a patient with enough time to harm themselves without staff present to intervene. Findings: An observation tour was conducted on 2/27/2024 at 9:16 AM with the Director of Quality, Staff #3, and the Assistant Chief Nursing Executive, Staff #6. Upon entering Unit 7, a centralized nursing station and a large day room (a large area used by both male and female patients as a common area) were observed. There were 2 separate patient hallways. Patient rooms were observed in each hallway. One side was for female patients, Unit 7A, and the other side was for male patients, Unit 7B. At the entry of each hallway was a double door that the staff referred to as a “Smoke” door. Each door remained open so that patients were able to move around freely between the patient hallways and the day room. The doors were held open by a large magnet and in sync with the fire alarm. An automatic door closure and three hinge points were observed on each door. The Geriatric Unit had 1 double door that was opened to the patient hallway. This door remained open at all times so that patients could move freely within the locked unit. The unit had two hallways that were separated by a centralized nursing station. One hallway was used for female patients and the other was used for male patients. The double door that was referred to as a “smoke door” was held open by a large magnet and in sync with the fire alarm. An automatic door closure and three hinge points were observed on each door. The metal door closures, and hinge points presented a risk for self-harm to all patients. The door closures and hinge points would support the weight of a patient and could be used as a ligature to hang themselves. An interview was conducted on 2/27/2024 at 12:50 PM with Staff #4. Staff #4 was asked if the ligature risks had been identified and if there was a plan to correct them. Staff #4 replied, “The ligatures were identified in the annual risk assessment. We were placed on a ligature remediation plan and we have had to send in a monthly report since 2019. In 2019 we presented a Capital Construction Project request that included the ligature points on the doors in Unit 7 and the Geriatric Unit and also included multiple other areas needed for repair to include ADA (Americans with Disabilities Act) requirements as well. We were granted the funding, except it was not enough to cover all the repairs. We replaced the patient door hinges to their rooms and restrooms. The restrooms had to be repaired to meet the needs of the disabled patients as well and that required more of the funding to go towards that. In 2021 we did another request but we did not receive any funding for repairs but were granted the funding for a new hospital.” She was asked if the construction on the new hospital had started and she confirmed it has not started and it may be later this year before it does. Staff #4 stated that in 2023 she requested additional funding for repairs needed that also included the doors with ligature points on Unit 7 and the Geriatric Unit but that request would not be looked at until the year 2025. I have ordered concealed door closures for those doors but they have been on back order.” A review of an email provided by the facility confirmed the order was placed on 12/05/2023 for the concealed door closures. A follow-up email was presented for review confirming the concealed door closures were to arrive from the manufacturer on 3/21/2024. During an interview with Staff #4 it was confirmed that the concealed door closure would not conceal the ligature on the door closures or the hinge points on the door frame. A review of the documents titled, “Capital Construction Project Request” for 2019, 2021, and 2023 confirmed the request to replace the ligatures observed in Unit 7A, Unit 7B, and the Geriatric Unit. An interview was conducted with the Chief Nursing Executive (CNE) Staff #5 on 2/27/2024 at 2:20 PM. CNE Staff #5 was asked what process was in place to ensure that staff were able to visualize all patients entering and exiting through those open doors to ensure their safety. CNE Staff #5 replied, “The nursing station is right by the doors.” She was then asked if she could confirm that someone was always at the nursing station and watching the hallway to ensure safety and she confirmed she could not say there was always staff with a visual of the doors that contained the ligature risks. At the time of the survey Unit 7A had 7 patients, Unit 7B had 17 patients, and the Geriatric Unit had 23 patients. During an interview on 2/27/2024 at 2:45 PM with Registered Nurse (RN) Staff #9 and RN Staff #11 it was confirmed no one was assigned daily to monitor the area where the ligature risks were present. Also, it was confirmed that the ligature risks on the doors posed a threat to patient safety.”