Sutter Yuba Behavioral Psychiatric Health Facility Unit Safety Improvement and Funding

Recommendations 9

• R1
  Physical Environment - Access Control / Security - (Potential Vulnerability) General Building; Behavioral The updates to access control systems (badge access to staff break area), in Health; Support Services;Care of the Behavioral Health conjunction with existing magnetic locks and self-closing/self-securing/locking doors appears to appropriately manage the risks associated with patient Patient; Environment of Care; Safety and Security; Policy,Guidelines and Process elopement. There are a number of doors throughout the unit (see ligature risk assessment Design; ProcessImprovement; Issue Analysis for detail) that do not self-close/self-secure/lock; these doors provide access to spaces in which there are ligature and other risks to patients and/or staff. & Prioritization; This includes the medication room door, which requires modification (or perhaps replacement) in order to appropriately support the dispensing of medications to A-0144 §482.13(c)(2); A-0701 §482.41(a); A-0724 §482.41(c)(2) patients while maintaining the safety of staff. (OM) Recommendation: It is recommended that corrective actions as outlined in the ligature risk assessment be implemented through the Sutter County General Services work order process; while a dutch door is a common strategy for medication rooms, space considerations, etc. may indicate modification of the door to include a secure service hatch, an example of which can be found here: https://www.capecodsystemscompany.com/store/ccskg167,product.asp
• R2
  Physical Environment - Ligature Risks - (Potential Vulnerability) General Building; Behavioral There are a number of ligature risks present throughout the environment, Health; Care of theBehavioral Health Patient;Environment of Care; Safety including spaces (rooms, bathrooms) in which patient activities can be unobserved. See ligature risk assessment for detail of findings. and Security; Policy, Guldelines and Process Design; A-0144 §482.13(c)(2);A-0701 §482.41(a); A-0724§482.41(c)(2) (SM) Recommendation: Implement corrective actions through Sutter County General Services work order process.
• R3
  Physical Environment - Patient Furnishings - (Potential Vulnerability) General Building; Behavioral In patient rooms throughout the facility, the bedside tables are not of Health; Environment of Care; ligature-resistant design/construction. There are metal loops on the front of the 117
• R4
  Physical Environment - Security of Exterior Perimeter / Exterior Patient Areas - (Potential Vulnerability) Behavioral Health; General The current chain link fencing arrangement, including access gates, etc. do not Building; Care of the provide the highest level of protection against elopement, passing of contraband, Behavioral Health Patient; etc. Additionally, there are ligature and elopement risks associated with the Environment of Care; Safety and Security; Policy, overhead shelter arrangement. Guidelines and Process Design; Process Improvement; Issue Analysis & Prioritization; A-0144 §482.13(c)(2); A-0701 §482.41(a); A-0724 §482.41(c)(2) (SM) Recommendation: It is recommended that consideration be given to a solid surface enclosure that provides protection against patient elopement (no points where grip, etc. can be established). An example of a potential solution can be found here: https://trexfencing.com/project-spotlight-acadia-riverwoods-10-tall-fence/ A design such as this, with "built-in" accommodations to allow for patients to continue to interact with visitors, should help to provide an appropriately safe and healing environment. To that end, it is also advisable that a behavioral health environmental design resource be consulted to assist in the design and sourcing of materials; an example of such a firm can be found here: https://www.bhfcllc.com/ Priority 3
• R5
  Physical Environment - Cleaning of Patient Areas - (Potential Vulnerability) General Building; Behavioral In several locations, particularly in the seclusion rooms, there was evidence of Health; Environment of Care; sub-standard detail cleaning. The bases of the seclusion room beds were Infection Prevention; Policy, noticeably solled and there were areas of the floor that were stained. Guidelines and Process Design; Educational Support at the Point of Care and Service; A-0701 §482.41(a); A-0724 §482.41(c)(2); A-0750 482.42(a)(3) (SM) Recommendation: Recommend reviewing detail cleaning expectations with EVS leaders/line staff, in coordination with Infection Prevention resources, to ensure 118
• R6
  Physical Environment - Exterior Signage - (Potential Vulnerability) General Building; Behavioral The exterior signage identifying the facility has been appropriately upgraded, but Health; Environment of Care; has not yet been provided with illumination (internal or external). Policy, Guidelines and Process Design; A-0701 §482.41(a); A-0724 §482.41(c)(2); A-0726 §482.41(c)(4) (SM) Recommendation: As the current signage does not appear to support internal illumination, it is recommended that external illumination be installed, in accordance with municipal guidance for sign illumination.
• R7
  Physical Environment - Hazardous Materials & Wastes Risks - (Potential Vulnerability) General Building; Behavioral In the utility room in the seclusion room area, there were several unlabeled Health; Safety and Security; spray bottles with liquid contents. All secondary containers must be labeled in Policy, Guidelines and accordance with the OSHA Hazard Communications Standard. Process Design; Educational Support at the Point of Care and Service; A-0701 §482,41(a); A-0724 §482.41(c)(2) (SM) Recommendation: Ensure all secondary containers, including spray bottles are labeled in accordance with: https://www.osha.gov/Publications/OSHA3636.pdf; provide education to line staff as applicable.
• R8
  Utility Systems Management - Maintenance of Utility Systems - (Potential Vulnerability) General Building; Behavioral During the facility tour, it was noted that the return / exhaust fans in several of Health; Environment of Care; the patient bathrooms and the shower room were not operating. Equipment Management; Policy, Guidelines and Process Design: A-0701 §482,41(a); A-0724 §482.41(c)(2); A-0726 §482.41(c)(4) (SM) Recommendation: Implement corrective actions through work order process; monitor for ongoing compliance. Priority 4
• R9
  Life Safety Management - Corridor Doors - (Potential Vulnerability) The corridor door for patient room 20 had holes in the door, potentially General Building; Behavioral Health; Environment of Care; increasing the risk of smoke passage. Life Safety Code; Policy, Guidelines and Process Design; A-0701 §482.41(a); A-0724 119 §482.41(c)(2); A-0710§482.41(b); K-363 (SM) Recommendation: Door should be repaired through work order process and monitored for ongoing compliance, 120