Environmental Suicide Risk Assessment Report...Western State (Building 28) Lakewood, WA...
15
229 Whitney Drive Barrington, IL 60010 mslhealthcare.com Office : 888 951 1114 Fax : 888 951 1117 Environmental Suicide Risk Assessment Report Western State (Building 28) Lakewood, WA 7/2/2018 to 7/3/2018
Transcript of Environmental Suicide Risk Assessment Report...Western State (Building 28) Lakewood, WA...
229 Whitney Drive Barrington, IL 60010 mslhealthcare.com Office : 888 951 1114 Fax : 888 951 1117
Environmental Suicide Risk Assessment Report
Western State (Building 28)Lakewood, WA
7/2/2018 to 7/3/2018
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Space Observed Potential Suicide Risk RiskClassification Potential Mitigation ActivitiesRoom
BH Corridor Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingOne-to-one observation
HBuilding 28 main corridor
BH Corridor Door closer, exposed (Ligature)BH Common Area Remove door closerOne-to-one observation
HBuilding 28 main corridor
BH Corridor Door handle and hinges, standard (Ligature)BH Common Area Replace with ligature-resistant door handleOne-to-one observation
HBuilding 28 main corridor
BH Corridor Exit signs not flush to ceiling or wall (Ligature)BH Common Area Mount exit signs flush to ceiling or wallOne-to-one observation
HBuilding 28 main corridor
BH Corridor Fire extinguisher cabinet, protruding (Ligature)BH Common Area Provide recessed extinguisher cabinetOne-to-one observation
MBuilding 28 main corridor
BH Corridor Hand rails, open (Ligature)Wood on one side and metal on the other side ofcorridor
BH Common Area Provide ligature-resistant hand railsOne-to-one observation
HBuilding 28 main corridor
BH Corridor Other attachment points (Ligature):Wooden boxesPendent alarm box
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HBuilding 28 main corridor
BH Corridor Other attachment points (Ligature):Access panel and convex mirrorElevator expansion joint
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HBuilding 28 main corridor
BH Corridor Sprinkler heads, standard (Ligature)BH Common Area Replace with ligature-resistant sprinkler headsOne-to-one observation
HBuilding 28 main corridor
BH Corridor Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
MSL Healthcare Partners, Inc.229 Whitney DriveBarrington, IL 60010p: 888.951.1114
RPA, a JENSEN HUGHES company500 Cross Keys Office ParkFairport, NY 14450p: 585.223.1130
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purposeof aiding the organization in its own self- assessment activities, and is a component of that self-assessment. Self-assessments have no direct impact on the officialfindings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 2
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Corridor Conduit, exposed (Ligature)BH Common Area Remove or enclose conduitOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Door closer, exposed (Ligature):Door handle
BH Common Area Remove door closerOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Door handle, standard (Ligature)BH Common Area Replace with ligature-resistant door handleOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Exit signs not flush to ceiling or wall (Ligature)BH Common Area Mount exit signs flush to ceiling or wallOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Nurse call lights, wall mounted (Ligature):Not flush to ceiling
BH Common Area Mount nurse call lights on the ceilingOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Other attachment points (Ligature):Pendent alarm boxLocker doors gaps
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Other attachment points (Ligature):Convex mirrors not flush to ceilingWooden cabinet
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Other attachment points (Ligature):Washer water connections exposedElectrical outlets do not have taper proof screws
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Telephone with cord (Ligature)BH Common Area Provide wall phone with slanted top and short cordOne-on-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Corridor Water fountain (Ligature):F7 has a double unit and wooden cover has gap attop corners
BH Common Area Remove water fountainOne-to-one observation
HCorridors: F7; F3; F6; F2;F5; F1; F8; F4
BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment pointsOne-to-one observation
HF1- 20, 23, 24, 28, 29Rooms
BH Patient Room Other attachment points (Ligature):SinkToiletMirrorGrab bars (2 types used)
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF1- 1-29 Rooms
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 3
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Room Window, operable (Harm)BH Dedicated Space Seal windowOne-to-one observation
HF1- 1-29 Rooms
BH Counseling Room White board ledges (Harm)Cabinet handlesLay in ceiling
BH Common Area One-to-one observation LF1- 159A Interview room
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation H F1- 58 Exam room
BH Patient Room Lamp, not flush to ceiling (Ligature)BH Dedicated Space Provide angled or recessed lampOne-to-one observation
HF1- 7, 9, 10, 15, 16, 17,21, 22, 26 Rooms
BH Exam Room Cabinets, handles and hinges (Ligature)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation MF1-58 Exam
BH Exam Room Door closer, exposed (Ligature)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Door handle, standard (Ligature)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Hooks, fixed (Ligature)BH Common Area One-to-one observation HF1-58 Exam
BH Exam Room Medical equipment (Ligature):Otoscope and BP wall mountedLampViewerCart
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HF1-58 Exam
BH Exam Room Oxygen cylinder (Harm)Rack with chain
BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HF1-58 Exam
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 4
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Exam Room Shelves, free standing metal (Ligature):BH Common Area Remove wall mounted shelvesOne-to-one observation
HF1-58 Exam
BH Tub Room, Corridor Other attachment points (Ligature):SAME AS F7 and F3Only used for storage
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF2 Tub room
BH Patient Room Drawers, removable (Ligature, Harm)BH Dedicated Space Remove drawersProvide furniture with open shelvesOne-to-one observation
HF2- 16-21 Rooms
BH Bathroom, Corridor Hinges, standard (Ligature)Wooden cabinet
BH Dedicated Space Replace with continuous hingesOne-to-one observation
HF4- Women's bathroom
BH Patient Room Door handle, loose (Ligature)BH Dedicated Space Add door handle inspection to EOC roundsOne-to-one observation
HF4-23
BH Bathroom, Corridor Other attachment points (Ligature):Shower door lock
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF5
BH Bathroom, Corridor Screws, non-tamper-resistant (Ligature, Harm)Light switch
BH Dedicated Space Replace with tamper-resistant screwsOne-to-one observation
HF5
BH Patient Room Other attachment points (Ligature):Light fixture gaps
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF5- 1-3, 12-23; F8- 27,24, 21, 12, 8; F4-5
BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment pointsOne-to-one observation
HF5- 12; F8- 21
BH Patient Room Other attachment points (Ligature):SinkToiletGrab bars style and gapsMirror not flush
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF5-18, 19, 13, 12; F8- 18,14, 13; F4-20, 19
BH Bathroom, Corridor Other attachment points (Ligature):Hand dryer not flushUrinal top corner not flush
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF5; F4
BH Bathroom, Corridor Dispenser, paper towel, breakable (Harm)BH Dedicated Space Replace with unbreakable dispenserOne-to-one observation
HF5; F8; F4
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 5
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Bathroom, Corridor Faucet (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation
HF5; F8; F4
BH Bathroom, Corridor Other attachment points (Ligature):Access panelsAccess panel gap (F8)Closet key lock (F8)
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF5; F8; F4
BH Patient Bathroom Mirror, not flush to wall (Harm)BH Dedicated Space Replace with unbreakable mirrorOne-to-one observation
HF6- 1-24; F2- 1-21 Rooms
BH Patient Bathroom Sink, shape (Ligature)BH Dedicated Space Replace with ligature-resistant sink HF6- 1-24; F2- 1-21 Rooms
BH Patient Bathroom Grab bars, gaps (Ligature):Two types used
BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HF6- 13, 19, 20; F2- 15, 21Rooms
BH Tub Room, Corridor Other attachment points (Ligature):Same as F2 plusMetal shelvesCabinet lock and latch
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF6- E203
BH Exam Room Cabinets, handles and hinges (Ligature)BH Common Area One-to-one observation HF6- E258; F2- F258
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation MF6- E258; F2- F258
BH Exam Room Door closer, exposed (Ligature)BH Common Area One-to-one observation HF6- E258; F2- F258
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HF6- E258; F2- F258
BH Exam Room Medical equipment (Ligature)BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HF6- E258; F2- F258
BH Exam Room Other attachment points (Ligature):ShelvingMagnetic door hold opens
BH Common Area Remove attachment points as feasibleOne-to-one observation
HF6- E258; F2- F258
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 6
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Exam Room Oxygen cylinder (Harm)BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HF6- E258; F2- F258
BH Exam Room Sharps container (Ligature, Harm, Contraband)BH Common Area Remove sharps containerOne-to-one observation
HF6- E258; F2- F258
BH Exam Room Sink, exposed plumbing (Ligature)BH Common Area Cover exposed plumbingOne-to-one observation
HF6- E258; F2- F258
BH Group Room Door handle, standard (Ligature)BH Common Area Replace with ligature-resistant door handleDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Group Room Lamp, breakable (Harm)BH Common Area Provide tamper-resistant lampDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Group Room Other attachment points (Ligature):TV cabinets with lock and chain
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Group Room Other attachment points (Ligature):TV door hinge and rubber bumperF6- E39: TV Electrical outlet and conduit
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Group Room Other attachment points (Ligature):TV cabinet hinge and lock
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Group Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MF6- E3 7, 39; F2- F36, 37;F1-37, 39; F5-37, 39; F8-37, 39; F4- 37, 39
BH Bathroom, Corridor Other attachment points (Ligature):Hand dryer outlet electrical outlet, conduit, andscrews
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF6- Men's bathroom
BH Patient Room Window, knobs (Harm)BH Dedicated Space Remove knobsOne-to-one observation
HF6-2-26; F2- 2-21 Rooms
BH Patient Room Bed, hospital, or open side rails (Ligature)BH Dedicated Space Use hospital beds only if medically necessaryProvide solid headboard, footboard, and side railsProvide covers for headboard, footboard, and side railsOne-to-one observation
HF6-24; F2- 29; F4-13
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 7
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Room Door handle, Loose (Ligature):Door strike plate loose: F6- 17 and F2 and F6-Showers, F2- Group room F39
BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation
HF6-6, 17, 26; Rooms
BH Counseling Room Cabinets, handles (Ligature)BH Common Area One-to-one observation MF6; F2 Interview rooms
BH Conference Room Hinges, top cap missing (Ligature)BH Common Area Replace with continuous hingesDirect observation of group
MF6; F2 Interview rooms
BH Conference Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MF6; F2 Interview rooms
BH Patient Bathroom Sink, shape (Ligature)BH Dedicated Space Replace with ligature-resistant sink HF6; F2- Room 1
BH Shower, Corridor Door closer, exposed (Ligature):Also door lock
BH Dedicated Space Remove door closerOne-to-one observation
HF6; F2; F1 Showers
BH Exam Room Cabinets, hinges (Ligature)BH Common Area One-to-one observation HF7- 0C61b; F3- 0C58
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation MF7- 0C61b; F3- 0C58
BH Exam Room Door closer, exposed (Ligature)BH Common Area One-to-one observation HF7- 0C61b; F3- 0C58
BH Exam Room Door handle, standard (Ligature)BH Common Area One-to-one observation HF7- 0C61b; F3- 0C58
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HF7- 0C61b; F3- 0C58
BH Exam Room Medical equipment (Ligature):ScalePortable BPOtoscopeBP wall unitView boxExam table
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HF7- 0C61b; F3- 0C58
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 8
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Exam Room Other attachment points (Ligature):Door and wall magnetic door hold opens0C58 electrical outlet not hospital grade
BH Common Area Remove attachment points as feasibleOne-to-one observation
HF7- 0C61b; F3- 0C58
BH Exam Room Oxygen cylinder (Harm)BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HF7- 0C61b; F3- 0C58
BH Exam Room Screws, non-tamper-resistant (Ligature, Harm)BH Common Area One-to-one observation HF7- 0C61b; F3- 0C58
BH Exam Room Sharps container (Ligature, Harm, Contraband)Wall mounted hook holding sled
BH Common Area Remove sharps containerOne-to-one observation
HF7- 0C61b; F3- 0C58
BH Exam Room Shelves, wall mounted and floor, and metal racks(Ligature)
BH Common Area Remove wall mounted shelvesOne-to-one observation
HF7- 0C61b; F3- 0C58
BH Exam Room Sink, exposed plumbing (Ligature)BH Common Area Cover exposed plumbingOne-to-one observation
HF7- 0C61b; F3- 0C58
BH Seclusion Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment points, if not in useOne-to-one observation
HF7- D056; F3- DC56
BH Seclusion RoomBathroom
Grab bars, open (Ligature)Are not ligature proof and too short
BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HF7- D056; F3- DC56
BH Seclusion Room Furniture, moveable (Barricade):Locked down with chain and lock
BH Dedicated Space Replace with heavy furnitureBolt furniture to floorOne-to-one observation
HF7- D056; F3- DC56; F4Observation
BH Seclusion RoomBathroom
Faucet, still ligature risk (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation
HF7- D056; F3- DC56; F4-Observation
BH Seclusion RoomBathroom
Other attachment points (Ligature)Access panelDoor stop
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7- D056; F3- DC56; F8;F5; F4
BH Conference Room Cabinets, handles (Ligature)BH Common Area Replace with ligature-resistant cabinet handlesDirect observation of group
MF7- D059; F3- DC59
BH Conference Room Other attachment points (Ligature):Door hinge caps missingDoor stop
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MF7- D059; F3- DC59
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 9
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Conference Room Pictures, artwork, boards, wall mounted (Ligature,Harm)White boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MF7- D059; F3- DC59
BH Patient Room Door handle, Loose (Ligature)Door strike plate loose (F3- DC 42, 43, 49)Door key lock loose (F3- DC 34)
BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation
HF7- DO 42, 43; F3- DC 22,26, 37, 42, 50, 51, 52, 49,48
BH Patient Room Drawers, bed removable (Ligature, Harm)BH Dedicated Space Remove drawersProvide furniture with open shelvesOne-to-one observation
HF7- DO13, 14, 16, 17, 22-52; F3DC- 13, 14, 16, 17,22-52
BH Patient Room Hinges, door hinges still at risk (Ligature)BH Dedicated Space Replace with continuous hingesOne-to-one observation
HF7- DO13, 14, 16, 17, 22-52; F3DC- 13, 14, 16, 17,22-52
BH Patient Room Other attachment points (Ligature):Clothes lockerWindow knobs
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7- DO13, 14, 16, 17, 22-52; F3DC- 13, 14, 16, 17,22-52
BH Patient Room Other attachment points (Ligature):BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7- DO13, 14, 16, 17, 22-52; F3DC- 13, 14, 16, 17,22-52
BH Patient Room Other attachment points (Ligature):SinkToiletGrab bars gapsMirror not flushLight fixture gap
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7- DO33, 34, 42, 43; F3-DC33, 34, 42, 43
BH Group Room Door handle, loose (Ligature)BH Common Area Replace with ligature-resistant door handleDirect observation of group
MF7- DO37
BH Group Room Lamp, breakable (Harm)Canned Lights
BH Common Area Provide tamper-resistant lampDirect observation of group
MF7- DO37, 39; F3- DC37,39
BH Recreation, Outdoor Conduit, exposed (Ligature)BH Common Area Enclose conduitMount conduit flush to wallDirect observation of group
HF7- Patio; F3- Patio
BH Recreation, Outdoor Other attachment points (Ligature):Window barsSprinkler eschusion
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HF7- Patio; F3- Patio
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 10
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Recreation, Outdoor Other attachment points (Ligature):Metal door overhangF7 door from Room DO39 to patio hinge coming out
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HF7- Patio; F3- Patio
BH Group Room Other attachment points (Ligature):TV door hinge and rubber bumperF7- DC39: TV Electrical outlet and conduit
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MF7- Patio; F3- Patio
BH Group Room Pictures, artwork, boards, wall mounted (Ligature,Harm)White boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MF7- Patio; F3- Patio
BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment pointsOne-to-one observation
HF7-1; F3- DC33
BH Bathroom, Corridor Faucet (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation
HF7; F3 Women's
BH Bathroom, Corridor Grab bars, gaps (Ligature)BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HF7; F3 Women's toilet
BH Bathroom, Corridor Other attachment points (Ligature):Seat cover dispenserAccess panelHand dryer gap
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7; F3 Women's Toilet
BH Bathroom, Corridor Other attachment points (Ligature/harm):Large wall mounted mirrorStall door hinges
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7; F3 Women's toilet
BH Bathroom, Corridor Door closer, exposed (Ligature)BH Dedicated Space Remove door closerOne-to-one observation
HF7; F3; F6; F2 Men'stoilet
BH Bathroom, Corridor Other attachment points (Ligature):Stall Door hingesStall latching
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7; F3; F6; F2 Men'stoilet
BH Recreation, Outdoor Lamp, breakable (Harm)Canned lights
BH Common Area Provide tamper-resistant lampDirect observation of group
HF7; F3; F6; F2 Patio
BH Recreation, Outdoor Other attachment points (Ligature):Window barsMetal strip over door
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HF7; F3; F6; F2 Patio
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 11
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Recreation, Outdoor Conduit, exposed (Ligature)BH Common Area Enclose conduitMount conduit flush to wallDirect observation of group
HF7; F3; F6; F2; F1; F5, F8,F4 Patio
BH Shower, Corridor Other attachment points (Ligature):FaucetPaper towel
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HF7; F3; F6; F2; F1; F5, F8,F4 Shower
BH Corridor Other attachment points (Ligature)Washer water connections are covered with plasticcover but holes present ligature riskWood cabinet hinges
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HF8 Corridor
BH Patient Room Other attachment points (Ligature):CPAP hinges
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
H F8- 14, 13; F4-5, 13
BH Patient Room Bed, hospital, or open side rails (Ligature)BH Dedicated Space Use hospital beds only if medically necessaryProvide solid headboard, footboard, and side railsprovide covers for headboard, footboard, and side railsOne-to-one observation
H F8- 23, 18, 14, 13, 8; F4-20, 19
BH Patient Room Shelves, wall mounted (Ligature)BH Dedicated Space Remove wall mounted shelvesOne-to-one observation
H F8- 27; F4-27
BH Bathroom, Corridor Mirror (Harm)BH Dedicated Space Replace with unbreakable mirrorOne-to-one observation
H F8; F4
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HF8; F5; F4
BH Exam Room Other attachment points (Ligature):Medical equipment: otoscope/BP, Viewer, Lamp,Cart, Scale, Portable BP unitO2 rack and chainConduitCabinet hinges and handlesFaucet standardSink piping exposedPaper towel dispenserWall mounted glove racksDoor closure exposedDoor handle and hinges standard
BH Common Area Remove attachment points as feasibleOne-to-one observation
HF8; F5; F4
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
Page 12
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Bathroom Drain cover, possible ligature (Contraband/harm)BH Dedicated Space Secure drain cover with tamper-resistant screwsOne-to-one observation
HShowers, all
BH Patient Bathroom Lamp, breakable (Harm)BH Dedicated Space Provide tamper-resistant lampOne-to-one observation
HShowers, all
BH Patient Bathroom Other attachment points (Ligature):Access panelDoor lock
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HShowers, all
BH Patient Bathroom Shower control (Ligature)BH Dedicated Space Replace with ligature-resistant shower controlOne-to-one observation
HShowers, all
BH Tub Room, Corridor Electrical outlets, non-tamper-resistant (Harm)BH Dedicated Space Provide tamper-resistant electrical outletsOne-to-one observation
HTub Rooms, all
BH Tub Room, Corridor Other attachment points (Ligature):Faucets fixtures standardPaper towel dispenserMirror not flushTub/shower water controlsEquipment stored in roomWall metal holderRoom being used for storage and not in use
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HTub Rooms, all
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
Western State (Building 28)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018 to 7/3/2018
High
Medium
Low
General/Acute Care
BH CommonArea
BH DedicatedSpace
RISK
CLASSIFICATION
1
57
20
1 2 3
4 5 6
7 8 9# Findings: 56
# Findings:
# Findings:
# Findings: BEHAVIORAL HEALTH SUICIDE RISK MATRIX EXPLANATION
We have modified The Joint Commission’s SAFER Matrix to reflect suicide risk by plotting thelikelihood of harm (H=high, M=medium, L=low) on the Y axis against the type of setting on the X axis.The setting itself may determine the likelihood of harm of some risks. The number of findings in aparticular box in the matrix is represented by the number in the upper right corner of the box.
All suicide risks would be scored by The Joint Commission at EC.02.06.01 EP 1.
Types of settings are as follows:
Behavioral Health Dedicated Space: This is the highest risk space in areas dedicated to behavioralhealth, whether in an inpatient unit or dedicated space in an emergency department. Dedicated spaceincludes patient rooms and corridors. Patients in these areas may not always have direct supervision.All risks in these areas are expected to be removed or mitigated with one-to-one observation.
Behavioral Health Common Areas: These are areas within dedicated behavioral health units in whichpatients are not without supervision, such as dining areas, group rooms, day rooms, etc. Risks in theseareas are to be documented and removed or mitigated as feasible.
General/Acute Care Areas: These are areas of the organization that are typically used by the non-behavioral health population, such as a general medical/surgical unit, intensive care unit, or a typicalemergency department treatment room or bay. Risks in these areas are to be identified and those risksthat are removable must be documented and removed when the space is occupied by a behavioralhealth patient. All remaining risks are to be mitigated by one-to-one observation.
NOTE: In outpatient behavioral health settings, patients are expected to be screened as to theappropriateness of the setting, therefore suicide risks are not scored in these settings.
Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.
229 Whitney Drive Barrington, IL 60010 mslhealthcare.com Office : 888 951 1114 Fax : 888 951 1117
Thank you for partnering with RPA and MSL Healthcare. Please contact me if you have any questions.
Thank You!
General RecommendationsNote 1: This assessment is only for the foot print of the building and does not include the exterior or any attachment to the exterior of the building. The grounds and any structure on the groundsare also not included.
Note 2: S-3 is under remodel. This assessment was done on what was completed at the time of the assessment.
Note 3: This assessment is to identify, at the organization's request, as many ligature and self harm points in areas where the patient has access, whether they are observed, accompanied, orunaccompanied. The organization will then determine their own risk for these areas.
Note 4: All elevator vestibules that patients access have in common: door bell, fire alarm and conduit, sprinkler head, some have a wall mounted phone with cord, door handle, and exposed doorclosure and hinges.
Note 5: All TV consoles have the same issues with the door hinges, door latch and lock, and strip across the top of the door.
Note 6: All patient rooms have the same issues with the clothes locker: long front panel, shelves have gaps, lower smaller shelf can be removed and used as a weapon as can the lower cabinetdoor, shelf brackets have gaps, top angle piece of locker is not flush to the wall, built in desk mounting brackets have gaps.
Note 7: Due to so many similar findings, the pictures attached may not be the exact picture, but due to similarities represent the findings in kind.
Note 8: The following rooms have been in use: F2 rooms 22-27; F8-19.
Troy [email protected]
