San Francisco General Hospital Trauma Center Environment of Care Risk Assessment Acute Psych Units (7A, 7B, 7C, and PES) INTRODUCTION The objective of this Safety Risk Assessment is to identify areas of vulnerability on the SFGH Behavior Health and PES, acute and non acute Psych units. This assessment was completed in collaboration with Environmental Health and Safety, Acute Psych and Facility Services. Contact persons: Kathy Ballou Director of Operations Acute Psychiatric Nursing Linda Henson EH&S, Safety Officer Micha Hoy Executive Project Manager Kathy Jung - Administrator Facility Services Sharon Wicher Chief of Nursing Officer The group started by reviewing an initial assessment conducted by Fong and Chan Architecture which identified items in the SFGH psychiatry acute and non acute environment that may have the potential to assist in bodily harm. A tour of each acute care and PES units was conducted to assess the environment of care, to identify whether patients have access to items that could be considered harmful to them. A review and discussion pertaining to the presence or lack of safety measures and identified issues of concerns took place. Where needed safety concerns and suggestions for immediate implementation of change or adding of safety features were pointed out. BACKGROUND 1) 7A is a locked adult inpatient unit which provides psychiatric care for adult patients age 18 or older with chronic and episodic mental illness in the acute phase. The units are open 24 hours/day, 7 days/week. The unit has a patient census of 21. The unit includes 1 private room, 2 seclusion rooms, 2 day rooms, occupational therapy room, and a kitchen. 7A provides evaluation and treatment of acute mental illness. The clinical specialty of 7A is the evaluation and treatment of patients experiencing acute mental illness who are Spanish speaking or bi-lingual/bi-cultural, or who have specific women s issues and concerns, and the treatment of gay/lesbian/bi-sexual/transgender patients experiencing acute mental illness. 2) 7B is a locked adult inpatient unit which provides psychiatric care for adult patients age 18 or older with chronic and episodic mental illness in the acute phase. The units are open 24 hours/day, 7 days/week. The unit has a patient census of 21. The unit includes 1 private room, 2 seclusion rooms, 2 day rooms, occupational therapy room, and a kitchen. 7B provides evaluation and treatment of acute mental illness. The clinical specialty of 7B is the evaluation and treatment of Asian Pacific patients experiencing acute mental illness as well as the evaluation and treatment of African-American patients experiencing acute mental illness. 3) 7C is a locked adult inpatient unit which provides psychiatric care for adult patients age 18 or older with chronic and episodic mental illness who are behaviorally stable and are at a non-
acute level of care. The units are open 24 hours/day, 7 days/week. The unit has a patient census of 18. The unit includes 1 private room, 1 seclusion room, 2 day rooms, occupational therapy room, and a kitchen. 7C provides ongoing treatment of non-acute mental illness. 4) PES provides 24-hour, 7-day a week emergency assessment, stabilization and disposition for acutely ill adult psychiatric patients who are San Francisco County residents. PES is the only designated evaluation facility for adult patients placed on psychiatric holds ( 5150 ). PES also provides psychiatric consultation and evaluation to patients in other services of SFGH when needed. As part of the Community Mental Health Services CMHS, PES provides emergency consultation to programs including Child Crisis Services within the CMHS system, as well as emergency assessment and hospital placement for San Francisco patients placed in sub-acute facilities whom are experiencing an acute exacerbation. GENERAL OBSERVATIONS 1. Employees wear photo ID s. 2. Emergency Exit doorway: Rear emergency stairwells have Detex alarm system in place. Routine access to the stairwells is restricted. Keys must be used to access emergency exits. 3. Alarm System: All units have panic alarm system in place, which alert each psych unit and SFSD. Staff has been issued personal safety alarms. 4. Telephones: All nursing stations, chart rooms, exam rooms and nurse manager s offices have telephones with emergency numbers which can be used to alert and call for assistance. 5. Security Mirror: All units have security mirror strategically placed. Security mirrors are placed at blind corners or areas where visibility is limited by staff to monitor patients. 6. Access Key control: Entry on and off the unit is via key control. Main double doors, bathrooms, kitchen, exam room, janitor s closet and OT rehabilitation are all controlled by key access. 7. Furniture Arrangement: In most cases furniture in patient rooms, exam room, interview/visiting rooms are strategically placed away from the entrance to the room for the purpose of patient/staff interaction and safety. Patient situated towards the window and staff near the door for quick exit. 8. Signage: Noted that there is no specific signage posted in area to warn patients/visitors of Zero tolerance for violent activity, misbehavior or contraband. 9. Security: Onsite SFSD staff responds to emergency and non-emergency calls for Police service 24 hours a day. 10. Cleanliness: Generally speaking units are relatively clean and in good repair. 11. Many locations throughout the Acute Psych Units observed carbon residue to electrical outlets suggesting patient tampering. This could be a fire safety issue. 12. There have been sporadic introduction of suicide prevention hardware and features throughout the Acute Psychiatric Units.
Generally speaking the environment of care on the units is relatively safe considering the building is thirty five years old. The infrastructure is in good repair. Some of the units have undergone painting, floor and wall resurfacing. There have been some areas in which remodeling or upgrades have been made such as on 7B, where door hinges have been replaced throughout the unit and windows have been retrofitted with safety screens. There are always opportunities for improvement. Listed below are items that should be considered when redesign or retrofitting is being considered. All exterior windows should be considered for screening. Prevention of breaking of window or patient attempt to jump or throw items through. (7B has screened windows throughout) All interior windows should be of unbreakable material. Accordion doors in patient and bath rooms could be potential ligature (hanging) risk. Corridor, Stairwell Detex boxes could be potential ligature (hanging) risk. 7C wall bumpers in corridors/hallways could be potential ligature (hanging) risk. Under sink piping in corridors/hallways could be potential ligature (hanging) risk. PES 1) Staff has concern with the in ability to keep doors open to the chart room open. Presently doors are held open with large bottle waters. This is a potential tripping hazard in the event that staff needs to move quickly to assist with patient event or if they need to close door for staff protection. 2) Consider enclosing fire alarm chime behind plexi-glass. 3) Consider installing door holder (magnet?) for 1B38 door to allow door to remain open. 4) Alcove at room 1B30 is out of line of site of staff entering hallway patient can hide.
INCIDENT EXPERIENCES (Unsafe Environment, Self Injurious Behavior, SFGH Property, Contraband) 2007-2010 Unit Item used to inflict harm Environment Body Part 6B Sharp piece of plastic Light fixture Inner arm 6B Bed Sheet Top of door Neck 6B Banged Head Wall Head 6B Throwing Chair/Garbage Chair/Garbage 6B Bed Sheet Cabinet Fixture Neck 6B Banged Head Window Head 6B x2 Burning Paper Electrical outlet 6B Lancet Mouth (swallowed) 6B Night stand/ceiling Neck vent 6B Staple/pencil Mouth (swallowed) 7A Sharp object Nurses station Cutting self 7A Razor Neck 7A Shower structure Neck 7A Pocket knife Forearms 7A Pocket knife Throat/neck 7A Shoelaces Neck 7A Bracelet Cutting self 7B Drink cleaning chemical Housekeeping cart Mouth 7B Threw himself Wall Body 7B Seclusion Door opened inward Body 7B Door Sally port/exit door Head/Body 7B Landry hamper Laundry bag Head 7B Box cutter/hypodermic Night stand needle/blade/crochet needle/ball of yarn /belt 7B Cigarette/talcum power Electrical outlet Mouth 7B Glass pipe/butane lighter Bathroom/door Mouth 7C Banging Head Front door Head 7C Sheet/gown Door hinge Neck 7C Chair Window/Chair 7C Paper Clip/battery Mouth 7C Paper clip Mouth PES Cover smoke detector Smoke detector/bed Arm PES Body Window Body PES Crack pipe/cig lighter PES Book matches PES Pills Mouth PES Syringe/white power
Fentenyl patch Mouth PES Knife Sally port Wrist PES Under bed Bed/restraint straps Neck PES Pills Sally port Mouth PES Pills Sally port Mouth PES Towel Door knob/grab bar 5D Window
The group took into consideration incident reports, interviews, inspections and actual walk through of locations throughout the psych dept. when determining the level of severity and risk involved to patient, visitor and staff. We were unable to identify any specific trends neither in review of actual events nor in near miss events. It was noted that nearly one third (1/3) of total incident experiences on 7A, 7B, 7C and PES involved contraband. This is brought up in hopes that present policies and procedures surrounding patient search/contraband will review and possibly revised. RECOMMENDATIONS SFGH Department of Psychiatry, Facility Service and Environmental Health and Safety submit recommendations based on review of incident reports, interviews, inspections and actual walk through of locations. The top six (6) items identified and prioritized for environment of care suicide risk on SFGH Acute Psychiatric units are listed below. Because SFGH lacks the presence of breakaway bars, rods or safety rails, the change out/replacement of Handicap grab bar/shower grab bar (B3/B7) is the number one recommendation for a plan of correction. Recommended Prioritization # 1. Handicap grab bar/shower grab bar (B3/B7) (33) 2. Door Hinges (changed out/replaced) (A3) (40) 3. Shower door/shower heads (B4/B6) (8) 4. Door Closers (removed and or replaced) (15) 5. Door Swing (changed out/replaced) (15) 6. Door Knobs (changed out/replaced with levers (?)) (21)
REFERENCE RESEARCH DATA (1996 & 1998) JOINT COMMISSION REVIEWS & SENTINEL EVENTS Issue 7 November 1998 Inpatient Suicides: Recommendations for Prevention JC reviewed 65 cases related to inpatient suicides. Most of the suicides occurred in psychiatric hospitals (34), followed by general hospitals (27) and residential care facilities (4). Of those cases in general hospitals, 14 occurred in psychiatric units, 12 in medical/surgical units and one in the emergency room. In 75 percent of the cases, the method of suicide was a hanging in a bathroom, bedroom or closet. Twenty percent of the suicides resulted from patients jumping from a roof or window. Causal factors identified of inpatient suicides include: The environment of care, such as the presence of non-breakaway bars, rods or safety rails; lack of testing of breakaway hardware; and inadequate security all can be root causes of inpatient suicides. The following risk reduction strategies have been recommended: Identifying and removing or replacing non-breakaway hardware. Weight testing all breakaway hardware Redesigning, retrofitting or introducing security measures (for example, locking mechanisms, patient monitors and alarms) Experts' Recommendations John Oldham, M.D., director of the New York State Psychiatric Institute in New York City, emphasizes that good patient care is the first step in preventing inpatient suicides. Organizations also should examine their environment of care to make sure that patients do not have access to items that could be considered harmful to them. Oldham recommends that facilities adopt the following practices: Make sure that items that can harm patients in the facility are addressed (for example, install appropriate shower heads, shower bars and closet bars that do not easily suggest such a use; do not leave doors open that should be closed; and do not give patients access to sharp objects and other potentially harmful items such as cleaning solvents). William Tucker, M.D., director of the Bureau of Psychiatric Services in the New York State Office of Mental Health in New York City, says that organizations should assess the degree of suicidal risk on admission, with the intent to place those with the highest risk on constant observation.