229 Whitney Drive Barrington, IL 60010 mslhealthcare.com Office : 888 951 1114 Fax : 888 951 1117
Environmental Suicide Risk Assessment Report
Western State (Building 29)Lakewood, WA
7/9/2018 to 7/10/2018
Western State (Building 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Space Observed Potential Suicide Risk RiskClassification Potential Mitigation ActivitiesRoom
BH Recreation, Outdoor Other attachment points (Ligature):Door handles standard: no picture as would haveincluded patients in picture
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HAll Patio doors
BH OutpatientCounseling Room
Blinds or shades, exposed, and cords (Ligature)BH Common Area One-to-one observation LChapel
BH OutpatientCounseling Room
Door closer, and hinges exposed (Ligature)BH Common Area One-to-one observation LChapel
BH OutpatientCounseling Room
Other attachment points (Ligature):LightsHeater and associated pipingConduitCross hanging from ceiling with chainsSprinkler piping
BH Common Area One-to-one observation LChapel
BH OutpatientCounseling Room
Screws, non-tamper-resistant (Ligature, Harm)BH Common Area One-to-one observation LChapel
BH Outpatient ActivityRoom
Ceiling, lay-in (Ligature, Contraband)BH Common Area Screen patients for appropriate settingDirect observation of group
L Clinic Dental
BH Outpatient ActivityRoom
Door handle, standard (Ligature):Door closure exposed
BH Common Area Screen patients for appropriate settingReplace with ligature-resistant door handleDirect observation of group
L Clinic Dental
BH Outpatient ActivityRoom
Faucet, standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant faucetDirect observation of group
L Clinic Dental
BH Outpatient ActivityRoom
Hooks, fixed (Ligature)BH Common Area Screen patients for appropriate settingRemove hooksReplace with ligature-resistant hooksDirect observation of group
L Clinic Dental
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 2
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Outpatient ActivityRoom
Shelves, and cabinets wall mounted (Ligature)BH Common Area Screen patients for appropriate settingRemove wall mounted shelvesDirect observation of group
L Clinic Dental
BH Outpatient Corridor Other attachment points (Ligature):Specimen boxes and shelf
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
LClinic LaboratoryCorridor
BH Outpatient Corridor Ceiling, lay-in (Ligature, Contraband)BH Common Area Screen patients for appropriate settingDirect observation of group
LClinic Medical
BH Outpatient Corridor Door handle, and hinges standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant door handleDirect observation of group
LClinic Medical
BH Outpatient Corridor Exit signs not flush to ceiling or wall (Ligature)BH Common Area Screen patients for appropriate settingMount exit signs flush to ceiling or wallDirect observation of group
LClinic Medical
BH Outpatient Corridor Other attachment points (Ligature):Nurse call lightScale
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
LClinic Medical
BH Outpatient Corridor Pictures, artwork, boards, wall mounted (Ligature,Harm):Wooden racks
BH Common Area Screen patients for appropriate settingSecure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
LClinic Medical
BH Outpatient ActivityRoom
Ceiling, lay-in (Ligature, Contraband)BH Common Area Screen patients for appropriate settingDirect observation of group
LClinic Medical Examrooms all
BH Outpatient ExamRoom
Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ExamRoom
Faucet, standard (Ligature)BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ExamRoom
Hinges, standard (Ligature)BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ActivityRoom
Hinges, standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with continuous hingesDirect observation of group
LClinic Medical Examrooms all
BH Outpatient ExamRoom
Hooks, fixed (Ligature):Lead apron racks
BH Common Area One-to-one observation LClinic Medical Examrooms 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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 3
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Outpatient ExamRoom
Other attachment points (Ligature):Same as other exam rooms
BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ExamRoom
Other attachment points (Ligature):Same findings as other exam rooms
BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ExamRoom
Other attachment points (Ligature):Same findings as other exam rooms.
BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient ActivityRoom
Other attachment points (Ligature):Sharps wall mountsGlove holders wall mountedMedical equipment: cart, chair, x-ray equipment
BH Common Area Screen patients for appropriate settingProvide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
LClinic Medical Examrooms all
BH Outpatient ExamRoom
Privacy curtain, non-breakaway (Ligature):All the curtains have metal chains instead of mesh.
BH Common Area One-to-one observation LClinic Medical Examrooms all
BH Outpatient Bathroom Dispenser, paper towel, breakable (Harm)BH Common Area Screen patients for appropriate settingOne-to-one observation
LClinic Medical Room #152
BH Outpatient Bathroom Electrical outlets, non-tamper-resistant (Harm)BH Common Area Screen patients for appropriate settingProvide tamper-resistant electrical outletsOne-to-one observation
LClinic Medical Room #152
BH Outpatient Bathroom Other attachment points (Ligature):Seat cover dispenserToilet flush pipingGrab barsMetal hooks on the wallMirror
BH Common Area Screen patients for appropriate settingProvide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
LClinic Medical Room #152
BH Outpatient Bathroom Other attachment points (Ligature):Door stop
BH Common Area Screen patients for appropriate settingProvide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
LClinic Medical Room #152
BH Outpatient Bathroom Sprinkler heads, standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant sprinkler headsOne-to-one observation
LClinic Medical Room #152
BH Outpatient ActivityRoom
Dispenser, paper towel, breakable (Harm)BH Common Area Screen patients for appropriate settingReplace with unbreakable dispenserDirect observation of group
L Clinic PT Gym, Rehab
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 4
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Outpatient ActivityRoom
Door closer, exposed (Ligature)BH Common Area Screen patients for appropriate settingRemove door closerDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Door handle, standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant door handleDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Exercise equipment (Ligature)BH Common Area Screen patients for appropriate settingDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Faucet, standard (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant faucetDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Fire extinguisher cabinet, protruding (Ligature)BH Common Area Screen patients for appropriate settingProvide recessed extinguisher cabinetDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Hinges, standard (Ligature)DoorsCabinets
BH Common Area Screen patients for appropriate settingReplace with continuous hingesDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Other attachment points (Ligature):Water fountainShelvingHand railVarious rehab equipment
BH Common Area Screen patients for appropriate settingProvide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Bulletin boards, and hooks wall mounted (Ligature,Harm)
BH Common Area Screen patients for appropriate settingSecure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
L Clinic PT Gym, Rehab
BH Outpatient ActivityRoom
Cabinets, handles and hinges (Ligature)BH Common Area Screen patients for appropriate settingReplace with ligature-resistant cabinet handlesDirect observation of group
L Clinic PT Gym, Rehab
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
HCorridor going to Chapel
BH Corridor Hand rails, open (Ligature)BH Common Area Provide ligature-resistant hand railsOne-to-one observation
HCorridor going to Chapel
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 5
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Corridor Other attachment points (Ligature)BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HCorridor going to Chapel
BH Activity Room Diffuser, wide openings (Ligature)BH Common Area Provide cover with small openingsDirect observation of group
ME- TRC Store Room
BH Activity Room Door closer, exposed (Ligature)BH Common Area Remove door closerDirect observation of group
ME- TRC Store Room
BH Activity Room Door knob and hinges, standard (Ligature)BH Common Area Replace with ligature-resistant door handleDirect observation of group
ME- TRC Store Room
BH Activity Room Faucet, standard (Ligature)BH Common Area Replace with ligature-resistant faucetDirect observation of group
ME- TRC Store Room
BH Activity Room Other attachment points (Ligature)Metal shelvesCarts
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME- TRC Store Room
BH Day Room Other attachment points (Ligature):Wood rackHeater vent grillNo picture due to patients
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME1 Day
BH Patient Room Other attachment points (Ligature):Clothes locker gapsClothes locker lower cabinet door
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- 133, 139, 140, 142,145, 149, 159, 161, 162,164, 166, 167, 168, 169,171; E7- 142, 128, 126,125, 123
BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment pointsOne-to-one observation
HE1- 134
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
HE1- 141, 136, 133; E7-111, 133, 137, 125, 122,123; E5- 112, 113, 115,116, 120, 122, 148, 145,142, 135, 139, 133; E3-112, 115, 122, 116, 128,120 122, 123, 135,137,139, 140, 142, 143,145, 146
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 6
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Shower, Corridor Shower head (Ligature)BH Dedicated Space Replace with ligature-resistant shower headOne-to-one observation
HE1- 152, 163
BH Shower, Corridor Other attachment points (Ligature):Heater
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- 163, 152, 146; E5-113, 119
BH Shower, Corridor Grab bars, gaps (Ligature)BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
H E1- 163, 152; E7- 146,134, 131, 119; E5- 146,120, 122
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HE1- A125
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation ME1- A125
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HE1- A125
BH Exam Room Hinges, cabinet standard (Ligature)BH Common Area One-to-one observation HE1- A125
BH Exam Room Hooks, fixed (Ligature)BH Common Area One-to-one observation HE1- A125
BH Exam Room Medical equipment (Ligature)CartExam lightTableWall BPPrivacy curtain, rolling
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HE1- A125
BH Exam Room Oxygen cylinder and mount (Harm)BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HE1- A125
BH Exam Room Pictures, artwork, boards, wall mounted (Ligature,Harm):Bulletin board
BH Common Area One-to-one observation HE1- A125
BH Exam Room Shelves, wall mounted and floor (Ligature):Desk wall mounted
BH Common Area Remove wall mounted shelvesOne-to-one observation
HE1- A125
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 7
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Corridor Door closer, exposed (Ligature)BH Common Area Remove door closerOne-to-one observation
HE1- A129 and 145
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
HE1- A129 and 145
BH Corridor Conduit, exposed (Ligature)BH Common Area Remove or enclose conduitOne-to-one observation
HE1- A129, 145; E2- 245
BH Corridor Door handle, standard (Ligature)Fire alarm pull station
BH Common Area Replace with ligature-resistant door handleOne-to-one observation
HE1- A129,145; E2- 245
BH Patient Room Other attachment points (Ligature):Hole through door
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- A144
BH Bathroom, Corridor Other attachment points (Ligature):Access panels
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- Toilets; E5-131
BH Bathroom, Corridor Other attachment points (Ligature):Hand dryer gaps
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- Toilets; E7- 119; E5-121, 122
BH Patient Room Other attachment points (Ligature):Door stop
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE1- Toilets; E7- 139,133,131; E5- 112, 120, 122,123; E3- 115, 116
BH Patient Room Sprinkler heads, standard (Ligature)BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation
HE1-133, 134, 136, 137,139, 140, 142, 144, 147,149, 159, 161, 162, 164,166, 167, 168, 169, 171:E7-119, 123-146; E5-110, 112, 113, 118, 120,148, 146, 145, 140, 133,135, 139, 137, 131; E3-112, 113, 116, 122, 123,135, 143, 145, 146
BH Day Room Blinds or shades, exposed, and cords (Ligature):Blind mounts
BH Common Area Remove exposed blinds or shades and/or cordsDirect observation of group
ME1-A157
BH Patient Room Lamp, attachment (Ligature):Round lights
BH Dedicated Space Provide angled or recessed lampOne-to-one observation
HE1-Toilets, 134, 136; E7-115-146; E5- 120; E3-112, 113, 115, 116, 118,120
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 8
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Recreation, Outdoor Other attachment points (Ligature):Security camera housing
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HE1; E2; E3; E4; E5; E6; E7Patio
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
HE1; E2; E3; E4; E5; E6; E7;E8
BH Corridor Door closer, exposed (Ligature)Hinges
BH Common Area Remove door closerOne-to-one observation
HE1; E2; E3; E4; E5; E6; E7;E8
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
HE1; E2; E3; E4; E5; E6; E7;E8
BH Corridor Other attachment points (Ligature):Convex mirrorsPendent alarm boxes
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HE1; E2; E3; E4; E5; E6; E7;E8
BH Corridor Pictures, artwork, boards, wall mounted (Ligature,Harm):Bulletin boardsWhite boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicOne-to-one observation
HE1; E2; E3; E4; E5; E6; E7;E8
BH Corridor Hand rails, open (Ligature)BH Common Area Provide ligature-resistant hand railsOne-to-one observation
H E1; E2; E3; E4; E5; E6;E7; E8 Corridor
BH Recreation, Outdoor Conduit, exposed (Ligature):BH Common Area Enclose conduitMount conduit flush to wallDirect observation of group
HE1; E2; E4; E5; E6; E7; E8-Patio
BH Recreation, Outdoor Lamp, attachment (Ligature)BH Common Area Provide angled or recessed lampDirect observation of group
HE1; E2; E4; E5; E6; E7; E8-Patio
BH Recreation, Outdoor Fencing (Ligature, Contraband, Elopement) and BarsBH Common Area Eliminate attachment pointsEnsure no cords are presentEnsure appropriate fence heightAngle fence inward at topInstall fence tight to groundDirect observation of group
HE1; E3; E5; E7- Patio
BH Corridor Nurse call lights, wall mounted (Ligature)BH Common Area Mount nurse call lights on the ceilingOne-to-one observation
HE1; E7; E8 Corridor
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 9
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Recreation, Outdoor Other attachment points (Ligature):Drain pipes (E1; E8; 6; E3)Sprinkler pipes (E8; E6)
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HE1; E8; E6; E3 Patio
ED BH Patient Room Lamp, attachment (Ligature):Gaps
BH Dedicated Space Provide angled or recessed lampOne-to-one observation
HE2- 233, 234
ED BH Patient Room Other attachment points (Ligature):Clothes locker gaps at top cornersCPAP hinges
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE2- 233, 237, 245, 248,269, 270, 271, 261, 263,264, 266, 271
BH Bathroom, Corridor Grab bars (Ligature):Bars too short
BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HE2- 234, 268
BH Bathroom, Corridor Other attachment points (Ligature):Access panel
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE2- 234, 268
ED BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment points if not in useOne-to-one observation
HE2- 236, 237, 268
ED BH Patient Room Bed, hospital, (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
HE2- 239
ED BH Patient Room Other attachment points (Ligature):239: Door stop236, 237, 241, 242: Heater grill
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE2- 239, 236, 237, 241,242
ED BH Patient Room Beds, with drawers (Ligature)BH Dedicated Space Provide ligature resistant clothes lockersOne-to-one observation
HE2- 240
ED BH Patient Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boards
BH Dedicated Space Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicOne-to-one observation
HE2- 241, 242
BH Corridor Door handle, standard and loose (Ligature)BH Common Area Replace with ligature-resistant door handleOne-to-one observation
HE2- 245
ED BH Patient Room Door handle, loose (Ligature):250: Door strike plate loose and damaged
BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation
HE2- 250, 268
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 10
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
ED BH Patient Room Other attachment points (Ligature):Sprinklers are not tamper resistant in all rooms but234, 261
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsMake tamper resistantOne-to-one observation
HE2- all patient rooms
BH Corridor Other attachment points (Ligature):Washer dryer connections cover (E2)E1 no cover over connections
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HE2; E1
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation ME2; E4- 268; E6- 268; E8
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HE2; E4- 268; E6- 268; E8
BH Exam Room Cabinets, hinges (Ligature)BH Common Area One-to-one observation HE2; E4-268; E6- 268; E8
BH Exam Room Door handle, standard (Ligature)BH Common Area One-to-one observation HE2; E4-268; E6- 268; E8
BH Exam Room Hooks, fixed (Ligature) and nurse call cover andhooks holding blue chairs
BH Common Area One-to-one observation HE2; E4-268; E6- 268; E8
BH Exam Room Other attachment points (Ligature):Door window shade knob
BH Common Area Remove attachment points as feasibleOne-to-one observation
HE2; E4-268; E6- 268; E8
BH Recreation, Outdoor Fencing (Ligature, Contraband, Elopement) andRails
BH Common Area Eliminate attachment pointsEnsure no cords are presentEnsure appropriate fence heightAngle fence inward at topInstall fence tight to groundDirect observation of group
H E2; E4; E6; E8- Patio
BH Bathroom, Corridor Other attachment points (Ligature)Heaters
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE2; E4; E6; E8-Showers/Bathing
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HE2; E6- 268; E8
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 11
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Exam Room Medical equipment (Ligature):Exam lightCartTableWall BP and otoscopePortable chairsX-ray viewer
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HE2; E6- 268; E8
BH Exam Room Oxygen cylinder (Harm)BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HE2; E6- 268; E8
BH Day Room Other attachment points (Ligature):Ceiling mounted projector screenNo picture due to patients
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME3 Day
BH Patient Room Other attachment points (Ligature):Bathroom door latch and screwed shut
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE3- 122, 123, 135, 137,139, 140, 145, 146
BH Exam Room Faucet, standard (Ligature)Paper towel shelf
BH Common Area One-to-one observation HE4
BH Corridor Fire extinguisher cabinet, protruding (Ligature)BH Common Area Provide recessed extinguisher cabinetOne-to-one observation
M E4 Corridor
BH Corridor Other removable objects (Harm):White boxMetal box at exit
BH Common Area Permanently attach or remove objectsDirect observation of group
H E4 Corridor
BH Corridor Water fountain (Ligature):Cover has a gap at topNo photo due to patients
BH Common Area Remove water fountainOne-to-one observation
H E4 Corridor
BH Recreation, Outdoor Other attachment points (Ligature):Faucet
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
HE4 Patio
BH Patient Room Other attachment points (Ligature):Door stops220: door hinge cap
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE4- 208, 213, 219, 237,220 bathroom door
BH Patient Room Door handle, loose (Ligature):211: door key lock loose
BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation
HE4- 211, 213, 212, 237
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 12
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Room Other attachment points (Ligature):Convex mirror over diffuser/vent
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE4- 216
BH Patient Room Door strike plate loose (Ligature):BH Dedicated Space Start a routine door maintenance program or during EOC rounds.One-to-one observation
HE4- 216, 217, 241, 239,251, 237, 233, 222, 224
BH Bathroom, Corridor Grab bars, open (Ligature):Gaps
BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HE4- 219, 213, 208
BH Patient Room Other attachment points (Ligature):Clothes locker gaps at top corners
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE4- 245, 246, 243, 242,240, 239, 222, 223, 233,235, 237
BH Patient Room Sprinkler heads, standard (Ligature)BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation
HE4- 248
BH Patient Room Lamp, attachment (Ligature):Gap between fixture and ceiling
BH Dedicated Space Provide angled or recessed lampOne-to-one observation
HE4- 249, 248, 246, 245,243, 242, 239, 237, 235,233, 222
BH Patient Room Bed, BH, with attachment points for restraints(Ligature)
BH Dedicated Space Remove the restraint attachment pointsOne-to-one observation
HE4- 249, 252
BH Patient Room Other attachment points (Ligature):Convex mirror not flush to ceiling
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE4- 259
BH Exam Room Medical equipment (Ligature):Exam lightWall BP and otoscopeExam tableDeskPortable monitorCart
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HE4- 268
BH Patient Room Other attachment points (Ligature):Heaters (all rooms have wall heaters that have acover with gaps)
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE4- All patient rooms
BH Patient Bathroom Dispenser, paper towel, breakable (Harm)BH Dedicated Space Replace with unbreakable dispenserOne-to-one observation
HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
BH Patient Bathroom Grab bars, gaps (Ligature):BH Dedicated Space Replace with ligature-resistant grab barsOne-to-one observation
HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 13
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Bathroom Lamp, attachment (Ligature):Round lights
BH Dedicated Space Provide angled or recessed lampOne-to-one observation
HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
BH Patient Bathroom Mirror, not flush to wall (Harm)BH Dedicated Space Replace with unbreakable mirrorOne-to-one observation
HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
BH Patient Bathroom Other removable objects (Harm):Flush piping coverMetal shelf
BH Dedicated Space Permanently attach or remove objectsOne-to-one observation
HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
BH Patient Bathroom Sink, faucets (Ligature)BH Dedicated Space Replace with ligature-resistant faucets HE4-219, 213, 208; E2-272, 238, 249, 267; E6-all bathrooms
BH Activity Room Faucet, standard (Ligature) and paper towelBH Common Area Replace with ligature-resistant faucetDirect observation of group
ME4-225 Token Store
BH Activity Room Hinges, standard (Ligature)Cabinet
BH Common Area Replace with continuous hingesDirect observation of group
ME4-225 Token Store
BH Activity Room Other attachment points (Ligature):Refrigerator door with lock and latchPendent alarm box
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME4-225 Token Store
BH Activity Room Sprinkler heads, standard (Ligature)BH Common Area Replace with ligature-resistant sprinkler headsDirect observation of group
ME4-225 Token Store
BH Day Room Telephone with cord (Ligature)BH Common Area Provide wall phone with slanted top and short cord HE4; E3; E6; E8 Day
BH Day Room Other attachment points (Ligature):ClockTV conduit
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME4; E6 Day
BH Group Room Other attachment points (Ligature)Door window shade knobs
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME5 Group; E3-108
BH Patient Bathroom Other attachment points (Ligature):Metal seat cover holder
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE5- 112, 113, 115, 116,118, 120, 122, 123; E1-Toilets
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 14
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Shower, Corridor Other attachment points (Ligature):Soap dish lip
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE5- 119
BH Patient Room Door handle, Loose (Ligature): E5- 120, 137, 149,113;Door strike plate: E5- 112, 115, 118, 116
BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation
HE5- 120, 137, 149, 113;E5- 112, 115, 118, 116
BH Patient Bathroom Other attachment points (Ligature):Desk "L" bracket support
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE5- 140
BH Patient Room Hinges, cap missing (Ligature):119: shower door corridor149: bathroom door148: bathroom
BH Dedicated Space Replace with continuous hingesOne-to-one observation
HE5- 149, 119; E3- 148
BH Seclusion Room Other attachment points (Ligature):Window knobsConvex mirrorsCamera cover gapsWindows
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE5- 152; E3- 151
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HE5- 168
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation ME5- 168
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HE5- 168
BH Exam Room Hinges, standard (Ligature)Cabinet
BH Common Area One-to-one observation HE5- 168
BH Exam Room Medical equipment (Ligature):Exam lightsWall mounted BP and otoscopeCartTablePortable equipment
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HE5- 168
BH Exam Room Oxygen cylinder (Harm)BH Common Area Remove cylinder if not medically necessaryOne-to-one observation
HE5- 168
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 15
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Exam Room Sharps container (Ligature, Harm, Contraband)BH Common Area Remove sharps containerOne-to-one observation
HE5- 168
BH Exam Room Shelves, wall mounted (Ligature)BH Common Area Remove wall mounted shelvesOne-to-one observation
HE5- 168
BH Shower, Corridor Other attachment points (Ligature):Sprinkler
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE57- 148, 119
BH Day Room Furniture, tables (Ligature):Desk "L" bracket
BH Common Area Replace with tables without attachment pointsDirect observation of group
ME6 Day
BH Laundry Room Hinges, and handle standard (Ligature)Door closure exposed on corridor side
BH Common Area Prohibit patient accessReplace with continuous hingesDirect observation of group
HE6- 258; E4-258
BH Laundry Room Other attachment points (Ligature)Washer connections
BH Common Area Prohibit patient accessProvide ligature-resistant
HE6- 258; E4-258
BH Patient Room Sprinkler heads (Ligature)BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation
HE7- 139
BH Group Room Other attachment points (Ligature):TV cabinet lock, latch, chain
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME7- 161, 157; E5 and E4-Group; E8- 261
BH Group Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boardsBulletin boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
ME7- 161, 157; E5 and E4-Group; E8- 261
BH Group Room Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group
ME7- 161, 157; E5 and E4-Group; E8- 261; E6-226
BH Group Room Other attachment points (Ligature):TV cabinet lock, latch, chain
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME7- 161, 157; E5-Group
BH Patient Room Other attachment points (Ligature):Wall lock
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE7- All 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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 16
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Recreation, Outdoor Other attachment points (Ligature):Hose reelTreeSecurity Camera
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
H E7- Patio
BH Patient Room Pictures, artwork, boards, wall mounted (Ligature,Harm):Bulletin boards
BH Dedicated Space Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicOne-to-one observation
HE7-136, 134, 131; E3-115, 116, 120, 122, 123,135, 137, 139, 140
BH Patient Room Window, operable (Harm):Knobs and latches
BH Dedicated Space Seal windowOne-to-one observation
HE7-136, 137, 139, 133,131, 130; E5-131-148
BH Exam Room Cabinets, hinges (Ligature)BH Common Area One-to-one observation HE7-157
BH Conference Room Cabinets, handles (Ligature): Lock, latchRolling Cart
BH Common Area Replace with ligature-resistant cabinet handlesDirect observation of group
ME7-157
BH Exam Room Ceiling, lay-in (Ligature, Contraband)BH Common Area One-to-one observation HE7-157
BH Exam Room Conduit, exposed (Ligature):Piping, light, vent, pipe hangers in closet
BH Common Area One-to-one observation HE7-157
BH Exam Room Dispenser, paper towel, breakable (Harm)BH Common Area One-to-one observation ME7-157
BH Exam Room Faucet, standard (Ligature)BH Common Area One-to-one observation HE7-157
BH Exam Room Hooks, fixed (Ligature)BH Common Area One-to-one observation HE7-157
BH Exam Room Medical equipment (Ligature):Wall mounted BP, otoscope, O2 mount with chain
BH Common Area Remove equipment not medically necessaryCover medical equipmentOne-to-one observation
HE7-157
BH Exam Room Shelves, (Ligature)BH Common Area Remove wall mounted shelvesOne-to-one observation
HE7-157
BH Bathroom, Corridor Faucet, (Ligature):Also Paper towel dispensers
BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation
HE7; E1; E5; E3 all toilets,shower rooms with sinks
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 17
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Patient Room Other attachment points (Ligature)In room sinks:Light over sinkPaper towel dispenserMirrorSinkFaucets
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE7; E3; E5; E1
BH Corridor Other attachment points (Ligature):Door magnetic hold opensBell
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
H E7; E8
BH Day Room Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group
ME7; E8; E1; E2; E3; E4; E5;E6 Day
BH Day Room Other attachment points (Ligature):TV cabinet lock, latch, chainPiano lock and latch
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
ME7; E8; E1; E2; E3; E4; E5;E6 Day
BH Day Room Sprinkler heads, (Ligature)BH Common Area Replace with ligature-resistant sprinkler headsDirect observation of group
ME7; E8; E1; E2; E3; E4; E5;E6 Day
ED BH Patient Room Other attachment points (Ligature):Light over sinkMirror not flushPaper towel dispenserMetal on wall
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 207, 223-246
ED BH Patient Room Other attachment points (Ligature):Round lightsWindow knobs
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 207, 223-246
ED BH Patient Room Other attachment points (Ligature):Sink faucetsClothes shelf
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 207, 223-246
ED BH Patient Room Pictures, artwork, boards, wall mounted (Ligature,Harm):Bulletin boards in room
BH Dedicated Space Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicOne-to-one observation
HE8- 207, 223-246
ED BH Patient Room Other attachment points (Ligature):Wood cover over toilet flush pipingGrab bar gap
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 212, 242, 244
BH Counseling Room Window, knobs (Harm)BH Common Area Seal windowOne-to-one observation
HE8- 226 Comfort room
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 18
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Bathroom, Corridor Shelves, wall mounted (Ligature)BH Dedicated Space Remove wall mounted shelvesOne-to-one observation
HE8- 229; E2- 265, Shower
BH Patient Room Sprinkler heads, standard (Ligature)BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation
HE8- 239, 237, 236, 234
BH Tub Room, Corridor Tub control (Ligature)BH Dedicated Space Replace with ligature-resistant tub controlOne-to-one observation
HE8- 248; E6; E4; E2
BH Tub Room, Corridor Other attachment points (Ligature):Metal shelfElectrical outlet and tub cordMultiple points on the tub itself
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 248; E6; E4; E2
BH Tub Room, Corridor Other attachment points (Ligature):Heater
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8- 248; E6; E4; E2
BH Tub Room, Corridor Tub faucet (Ligature)BH Dedicated Space Replace with ligature-resistant tubOne-to-one observation
HE8- 248; E6; E4; E2
BH Shower, Corridor Other attachment points (Ligature) BEING USED ASSTORAGE:Shower controlsHeaterDoor closureDoor hingeVentSeatAccess panelGrab bars
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HE8-220
BH Activity Room Cabinets, handles (Ligature):E219 lock and handles
BH Common Area Replace with ligature-resistant cabinet handlesDirect observation of group
MTRC
BH Activity Room Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group
MTRC
BH Activity Room Fire extinguisher cabinet, protruding (Ligature)BH Common Area Provide recessed extinguisher cabinetDirect observation of group
LTRC
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 19
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Activity Room Other attachment points (Ligature):Metal shelves attached to wall with "L" bracketMetal lockers locks and latches
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MTRC
BH Activity Room Other attachment points (Ligature):Wood cabinets handlesMetal filing cabinets handlesPartition connections
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MTRC
BH Activity Room Pictures, artwork, boards, wall mounted (Ligature,Harm)White boardsBulletin boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MTRC
BH Activity Room Door closer, exposed (Ligature)BH Common Area Remove door closerDirect observation of group
MTRC- 216A and B
BH Activity Room Door handle, standard (Ligature)BH Common Area Replace with ligature-resistant door handleDirect observation of group
MTRC- 216A and B
BH Activity Room Faucet, standard (Ligature)BH Common Area Replace with ligature-resistant faucetDirect observation of group
MTRC- 216A and B
BH Activity Room Hinges, standard (Ligature):Cabinet hinges
BH Common Area Replace with continuous hingesDirect observation of group
MTRC- 216A and B
BH Activity Room Other attachment points (Ligature):Paper towel dispenser
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MTRC- 216A and B
BH Activity Room Screws, non-tamper resistant (Ligature, Harm)BH Common Area Replace with tamper resistant screwsDirect observation of group
MTRC- 216A and B
BH Activity Room TV, wall mounted (Ligature)BH Common Area Enclose wall mountDirect observation of group
HTRC- 216A and B
BH Activity Room Ceiling, lay-in (Ligature, Contraband)BH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group
MTRC- 216B
BH Activity Room Other attachment points (Ligature):Counter supported by "L" bracketDoor with holes through it
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MTRC- 216B
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
Page 20
Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room
BH Activity Room Other attachment points (Ligature):Refrigerator lock and handlesCart with a TV on it
BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group
MTRC- 216B
BH Bathroom, Corridor Faucet, (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation
HTRC- Men and Women
BH Bathroom, Corridor Other attachment points (Ligature):Toilet and urinal piping box coverHand dryer
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HTRC- Men and Women
BH Bathroom, Corridor Other attachment points (Ligature):Stall door hingesPlastic on the wallDoor stop
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HTRC- Men and Women
BH Bathroom, Corridor Other attachment points (Ligature):Water fountain in corridor
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HTRC- Men and Women
BH Bathroom, Corridor Other attachment points (Ligature):Door lock and latch
BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation
HTRC- Women
BH Activity Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boardsOrganization boards
BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group
MTRC-216B
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 29)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/9/2018 to 7/10/2018
High
Medium
Low
General/Acute Care
BH CommonArea
BH DedicatedSpace
RISK
CLASSIFICATION
42
65
43
1 2 3
4 5 6
7 8 9# Findings: 72
# 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 Recommendations
Note 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 grounds are also not included.
Note 2: S-3 is under remodel. The 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, or unaccompanied. 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, and door handle and exposed door closure and
hinges.
Note 5: All TV consoles have the same issues with the door hinges, door latch and lock, 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 cabinet door, shelf brackets have
gaps, top angle piece of locker is not flush to the wall, and 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: not being used.
Note 9: This risk assessment was performed to identify as many ligature risks as possible. No environment can be totally ligature resistant, therefore as many potential ligature points were identified as possible.
Troy [email protected]