MHEOC Checklist.xlsx

Background

Background:

The idea of an Environment of Care Checklist to reduce the risk of suicide and para-suicidal behaviors grew out of the Patient Safety Workgroup, a subcommittee of the Performance Measures Workgroup. Dr. Ira Katz (Deputy Chief Patient Care Services Officer for Mental Health) asked us to first review the Root Cause Analysis Database to see if inpatient suicides and parasuicidal behaviors were in fact related to environmental factors. The results revealed that 54% of inpatient suicides and suicide attempts in VA occurred on inpatient psychiatry units or detox units. In addition, approximately 70% of the events were either hangings, cutting with a sharp object or drug overdoses, with hanging the largest category. Virtually all of the hangings used some environmental anchor that could be modified to reduce the risk of harm; and 39% of the cutting incidents used razor blades.

Based on this report, it made sense to develop an environmental checklist for use in VA mental health units. Dr. Katz approved of this course of action.

A national committee was formed to develop the checklist with the following charter:

Committee Charter: To develop a consensus environmental checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. A secondary product of the committee will be to add items to the checklist that consider environmental factors that reduce employee safety on mental health units. The checklist will not address procedures for determining whether a patient is at risk for suicide or reducing the risk of suicide through various mental health treatments. The focus will be on the environmental factors contributing to patient and staff safety. We will do this by reviewing existing checklists and adding to the checklists based on professional experience. The committee will also make recommendations for how to use the checklist in conducting environmental rounds on mental health units. This initiative is consistent with the Joint Commission patient safety goals and Dr. Katz's mental health initiatives within VHA as well as the current literature on prevention of suicidal behaviors (see Mann et al, Suicide Prevention Strategies: A systematic review. JAMA, 2005, v 294, 2064 -2074).

Committee Members:

MHEOCC Transmittal Letter Page &P of &N http://vaww.ncps.med.va.gov/Guidelines/mheocc/1167_D_2017-05-12.pdf General Instructions

Mental Health Environment of Care Checklist

VHA National Center for Patient Safety

Department of Veterans Affairs

Version 09-30-2020

Should you require further information, please contact Peter Mills, PhD from the National Patient Safety Center at peter.mills@va.gov, Gayle Iwamsa Ph.D, Office of Mental Health Operations and Suicide Prevention - Gayle.Iwamasa@va.gov.

MHEOCC, Instructions Page &P of &N http://vaww.ncps.med.va.gov/Guidelines/mheocc/1167_D_2017-05-12.pdf General Criteria

5.b. Are picture frames secured to the walls using tamper resistant screws or anchors?

6.b. Are receptacles and switches covered by metal plates that are secured by tamper resistant screws?

6.c. Are the electrical boxes flush mounted?

6.d. Are all receptacles provided with GFCI protection? GFCI-protected outlets, adequate number of outlets, short electrical cords. Equipment with cords should be located close to the wall outlet; cords should be too short to loop around the neck and secure to an anchor point for hanging. If the outlet will be used for medical equipment it should be tamper resistant but not GFCI as GFCI outlet may trip and shut off the equipment (added August 2008). As of August 2008 there are GFCI-Tamper Resistant outlets that should be used.

http://www.cooperindustries.com/content/public/en/wiring_devices/products/receptacles/residential/aspire/aspire_tamper_resistant_gfcis_9566tr_9569tr.html?_ga=2.252483850.203627272.1561398478-1792284201.1561398478

Link added June 2019 7 7.2.13.1.7 HVAC vents 7.a. Are HVAC vents flush with the wall?

7.b. Are HVAC vents secured with tamper resistant screws?

7.c. Are louvers designed so that they cannot be used to secure any item that might be used to attempt suicide by hanging?

12.b. Alcohol dispensers should not be on the walls in patient areas? Look at each item. All items must be secured to the wall in a manner that prevents removal or use as a weapon or for self-harm. It must be flush with the wall or beveled in a manner so that it cannot be used as an anchor for hanging. If lights are on the wall, the glass bulbs should not be easily accessed.

Alcohol based gels and foams may be consumed by patients and therefore should not be accessible to them. See question #19 below for guidance on sprinklers.

Updated March 2013

15.b. Are ceilings free of hanging objects such as plant hangers and wind chimes?

20.b. If windows open, are they restricted so that the maximum opening is 4 inches or locked to prevent them from being opened by a patient? Do staff know the location of the key need to unlock the window and is it accessible to them if it is needed? Updated November 2016.

20.c. Are windows inspected at least semi-annually to ensure locking mechanisms have not been compromised (added 9/01/2009) See below for glazing requirements from VA Master Specification Section 08810, Glass and Glazing. If the unit was designed as a mental health unit it is likely that the glazing meets the requirements. If the unit was converted from a different use, the glazing may not meet the requirements for mental health units. Consult with facility Engineering staff regarding use of Section 08810.

For Glazing Specifications please see: Section 08 80 00, Glazing @ http://www.cfm.va.gov/TIL/spec.asp#08

1. Mental health and behavioral science service for psychiatric, alcohol, and drug dependency treatment areas require "Security Glazing" assemblies, resistant to breakage and use as weapons.

2. Security (seclusion) rooms, including room doors, use 11 mm (7/16 inch) laminated clear glass, clear heat strengthened glass clad polycarbonate, or clear tempered glass clad polycarbonate.

3. For patient ward glazing use laminated assemblies of tinted, heat strengthened, clear, clear tempered, or clear heat strengthened glass.

4. Specify optional glazing of clear heat strengthened glass clad polycarbonate, or clear tempered glass clad polycarbonate for 11 mm inch (7/16) thick laminated glass.

Please see: Section 08 80 00, Glazing @ http://www.cfm.va.gov/TIL/spec.asp#08 21 7.2.13.1.21 Window frames 21.a. Are window frames designed to prevent them from being broken by a patient?

21.b. Are the windows frames free of projections or holes that could serve as an anchor point for hanging? Frames should be tamper resistant and shatter resistant and tested to make sure that they cannot be broken apart.

The following are the performance requirements for window frames in mental health units:

“Behavioral Health Interior Access Windows: Provide interior access windows designed to meet the 2711 Newton meters (Nm) (2000 ft-lb.) simulated human impact test in accordance with AAMA 501.8-13.”

23. b. If a gasket or sweep is used, it should be cut into sections that are short enough (e.g., 12 inches or less) so that if the gasket or sweep is removed it cannot be used for self harm.

23. c. Do corridor doors to patient sleeping rooms have an over-the-door alarm? Updated November 2019

23. d. Are all over the door alarms checked semi-annually to make sure they are still working properly? Updated November 2019 Because of Life Safety Code limitations regarding door swing into the corridor and corridor obstruction from a fully-opened door, corridor doors have traditionally been designed to swing into the room. For corridor doors in new construction it is recommended to install a door and frame assembly that will permit the door to swing in both directions. Normal operation could be door swing into the room, but if necessary (e.g., patient barricaded inside the room), staff could release the door stop so that the door could swing into the corridor. NOTE: The use of a wicket door (a door within a door) is also acceptable in both new and existing construction.

Refer to the Life Safety Code (NFPA 101) for the complete set of door requirements. Note: The 2012 Edition of the Life Safety Code has been changed (See 18.3.6.3.9.2 below) based upon a proposal by the VA to assist in the hardware selection for psyche facilities. It would essentially allow the option of using a roller latch (not previously permitted in new construction) along with no door handle to assist in meeting the Life Safety Code corridor door requirements. Contact: peter.a.larrimer@va.gov if you have questions.

Please Note: We have not been able to find a corridor door that completely eliminates all suicide hazards. Corridor doors must also be designed to limit the transfer of smoke so they cannot be cut down.

A Memo from 10N dated May 10, 2019 required all sleeping room corridor doors to have an over-the-door alarm by January 1, 2020.

23.1. 7.2.13.11.23.1 Interior Doors that do not need to limit the transfer of smoke 23.c. Are doors that are within rooms and that open to other in-room areas such as bath/shower/toilet areas (i.e., not corridor doors) designed to eliminate anchor points?

23. d. Are thick wooden cut-down doors removed and replaced by SER doors, soft suicide prevention doors or break-away curtains?

23. e. Are interior doors are inspected semi-annually to ensure that the top hinge is intact and that there are no anchor points?

Updated November 2016 For doors NOT opening to the corridor, the preferred door design is an angled top (hinge side higher) with an approximately 6-inch gap between the top of the door and the door frame. Doors that do not open to the corridor are not required to limit the transfer of smoke, so the dimension of the gap between the door and the frame is not specified. Doors to wardrobe cabinets or closets should be removed and shelves should replace rods and hangers.

Even with an angled top door, the presence of door latching hardware, including roller latches, provides an accessible anchor point to patients when ligatures are pinched between the door edge and the door frame.

Another potential anchor point may exist above the continuous (piano) hinge of an angled top door. While a continuous hinge is recommended over standard door (2 or 3 point) hinges, it is not without risk. The continuous hinge must have a “hospital cut” at the top providing a sloped surface for the entire top surface of the door.

If cut down doors or SER doors are installed in locked mental health units, then do one of the following:

a) Remove latching door hardware, (positive latching or roller latches) on cut down doors or SER doors. Fill any holes in the doors to remove potential anchor points. Trim back the latching edge of the door to create a gap of approximately 1 inch between the door and the door frame that will not permit a ligature to be pinched between them. Install a soft gasket material to the latching edge of the door that is cut into lengths not exceeding 12 inches.

or

b) Replace cut down doors equipped with any type of latching door hardware with soft break-away doors for bathrooms and showers.

See Patient Safety Alert AL10-03 (10/06/2009) 24 7.2.13.1.24 Hinges 25.a. Are swinging doors provided hardware that reduces the risk of the hardware being used as an anchor?

25.b. Are three point hinges designed and installed so they do not protrude providing an anchor point for hanging? Standard butt hinges, if used, must have a "hospital tip" that is beveled. Wherever possible use continuous piano hinges.

25.c. Are doors free of hold-open devices and self-closers that could be used as an anchor point for hanging? The dual-swing doors discussed in item 23 above are supported by a post at the top and bottom of the door and do not have hinges. Such hardware is acceptable as long as the gap at the top of the door is sufficiently small to reduce the risk that the post could be used as an anchor point. (Note it is not possible to completely eliminate the risk of a person threading a small lanyard around the post and using it to hang.) If piano hinges are used, it is recommended to use piano-type hinges that are flush-mounted to the door frame.

Note: The 2012 Edition of the Life Safety Code has been changed (See 18.3.6.3.9.2) based upon a proposal by the VA to assist in the hardware selection for psyche facilities. It would essentially allow the option of using a roller latch (not previously permitted in new construction) along with no door handle to assist in meeting the Life Safety Code corridor door requirements.

See: http://vaww.ceosh.med.va.gov/01FS/Pages/firesafety.shtml

27.b. Are closets free of clothes hangers (plastic, wood, and metal)? (Added September 2010)

27. c. Are doors on closets or wardrobe cabinets removed? Clothing rods of any type can be used as a ligature point for hanging and can be used as a weapon.

Doors on closets and cabinets should be removed so that they do not provide an anchor point for hanging.

Spring-loaded hooks designed for mental health areas should be used in lieu of closet rods and hangers.

27 7.2.13.1.27 Shelves 28.a. Are shelves in closets secured with tamper resistant fasteners and designed so they cannot be used as an anchor for hanging?

28.b. Are heavy items on shelves placed low to the floor and secured in place to prevent them from being removed?

29.b. Are racks designed so they cannot be used as an anchor point for hanging?

30.b. Is furniture designed to prevent it from being pulled apart or splintered to be used as a weapon for self-harm or harm to others? Examples of potential hazards are pieces of metal such as drawer roller assembly, or a part of a bed or chair that could be removed and used as a weapon.

30.c Is the furniture (e.g., chairs, stools, tables, beds, cabinets, shelves, desks) accessible to patients free of anchor points to prevent hanging? Are wheelchairs with anchor points are inaccessible to patients?

30.d Are floor guards on all furniture in the unit either a) attached to the furniture using tamper-resistant fasteners or b) removed from the furniture?

Furniture should be heavy and difficult to pick up and move; it should be made of wood or sturdy plastic; knobs and pulls should be designed to not support weight. Furniture should be low profile type so that it cannot be used by the patient to reach the ceiling.

Furniture should not have anchor points for hanging, or floor guards that can be removed by patients and used as a weapon or for self-harm.

Furniture in private areas such as bedrooms should have no anchor points. Heavy furniture should not be in bedrooms. Added November 2017.

Furniture, including wheelchairs, should be free of plastic, vinyl, or other materials that could be removed and used for suffocation or strangulation (Added March 2014).

http://vaww.office.ncps.med.va.gov/tools/pslog/edit.asp?id=937

31.b. Is the plumbing enclosed in a tamper-resistant enclosure to prevent access by patients?

31.c. Is under-sink storage secured?

31.d. Is the temperature of the hot water tested to ensure it will not cause a burn?

31.e. Do anchor points exist on the sinks or faucets (or other accessories)? (Added March 2012)

There should be no exposed piping or conduit in patient areas. The sink faucet should be a single unit with a round handle that is designed with a taper or a round lever so a noose would slip off with the weight of a person. A sensor type faucet is preferable since this has no lever. Hot water should be regulated so that it is 105 - 110 degrees F at the tap (see VHA Directive 2002-073, Domestic Hot Water Temperature Limits).

Sinks must not have any anchor points and the patient should not be able to hang from the sink itself. One design that achieves this is a vanity that extends from wall to wall. Added March 2013.

Faucets must also have no anchor points.

Are carts locked away when not in use? (January 2013) Can locks for storage cabinets on the unit be disabled by items that may be available to patients, such as plastic cards? (2014) All chemicals, housekeeping supplies and equipment, and maintenance carts and equipment must be secured or have someone in attendance.

33 7.2.13.1.33 Medical Equipment 34 a. Are devices such as blood pressure cuffs and other medical equipment kept inaccessible to patients? Also make sure that wheelchairs with anchor points are not accessible to patients.

34 b. Have patients with assistive devices been evaluated for their risk for using the device as a weapon or to barricade themselves in a room? Blood pressure cuffs can be placed around the neck and inflated, or the cords and hoses can be used for self harm or to harm others. Other medical equipment may present dangers also. These items should be kept in locked rooms or where a staff member is in attendance.

Practitioners should assess a patient’s suicide and fall risks, the need for assistive devices and the danger of the assistive device, on a case-by-case basis. The practitioners and the treatment team must weigh the risks vs. benefits for each patient and the environment as a whole. This assessment needs to include, at minimum, the patient’s risk for falls, the patient’s risk for suicide, aggression or aggressive behaviors on the part of the patient or other patients within the unit, and the ability of the device to barricade a door or be used as a weapon. It is suggested that physical therapy be consulted, as needed, to assist in developing an interdisciplinary plan of care that minimizes risk for injury from falls, self-harm behavior or of harm to others. Less complex options for patient mobility could be found to be more applicable (e.g., don’t permit use of a walker if a quad cane is equally effective and safe for the particular patient). Note that reassessment during a patient’s stay will be required if the patient’s behavior or suicidal status changes (e.g., if the patient become aggressive) or if the environment changes. Updated June 2011

See Patient Safety Alert: AL 11-06

33.1 7.2.13.1.33.1 Medical Equipment 33.1 a. Is all medical equipment, such as CPAP machines, blood pressure cuff, Oxygen tubing, and medical beds under direct line-of-sight observation by staff?

Added June 2018

Medical equipment can be used for self-harm. Medical beds and wheelchairs have anchor points for hanging. CPAP machines and oxygen tubing can be used for hanging or strangulation.

Direct line-of-sight observation is defined as constant observation of the patient by staff. Staff can observe multiple patients, but must remain in the area with patients, such that if a patient needs immediate intervention, the staff member can intervene and call other staff to help as needed. Observation by cameras cannot substitute for direct line-of-sight observation.

See: VHA DIRECTIVE 1167 Added August 2019:

NOTE: As of August 2019 it is acceptable to have wheelchairs, without high bars or modifications that increase the hanging risk, to be used by patients who are assessed to be at low-risk for suicide on mental health units at night with 15 min checks. Patients must be in single rooms (or double rooms where both occupants have wheelchairs and are assessed to be at low risk for suicide) close to the nursing station so that staff can ensure that other patients do not have access to the wheelchairs at night. During the day patients in wheelchairs should be under direct line-of-sight observation (this is keep other patients from accessing the wheelchair for self-harm or to harm others).

34 7.2.13.1.34 Trash bags Are trash cans in areas accessible to the patients free of plastic bags that can present a suffocation hazard?

Inspect ward and patient rooms. Also inspect for devices with detachable pieces that could be used to harm themselves or another e.g., wheelchairs with detachable pieces (e.g., arm rests, anti-tip parts, foot rest, etc.)

23. b. If a gasket or sweep is used, it should be cut into sections that are short enough (e.g., 12 inches or less) so that if the gasket or sweep is removed it cannot be used for self harm.

23. c. Do corridor doors to patient sleeping rooms have an over-the-door alarm? Updated November 2019

23. d. Are all over the door alarms checked semi-annually to make sure they are still working properly? Updated November 2019 Because of Life Safety Code limitations regarding door swing into the corridor and corridor obstruction from a fully-opened door, corridor doors have traditionally been designed to swing into the room. For corridor doors in new construction it is recommended to install a door and frame assembly that will permit the door to swing in both directions. Normal operation could be door swing into the room, but if necessary (e.g., patient barricaded inside the room), staff could release the door stop so that the door could swing into the corridor. NOTE: The use of a wicket door (a door within a door) is also acceptable in both new and existing construction. Wicket doors must not form anchor points (Added Sept 2020)

Refer to the Life Safety Code (NFPA 101) for the complete set of door requirements. Note: The 2012 Edition of the Life Safety Code has been changed (See 18.3.6.3.9.2 below) based upon a proposal by the VA to assist in the hardware selection for psyche facilities. It would essentially allow the option of using a roller latch (not previously permitted in new construction) along with no door handle to assist in meeting the Life Safety Code corridor door requirements. Contact: peter.a.larrimer@va.gov if you have questions.

Please Note: We have not been able to find a corridor door that completely eliminates all suicide hazards. Corridor doors must also be designed to limit the transfer of smoke so they cannot be cut down.

A Memo from 10N dated May 10, 2019 required all sleeping room corridor doors to have an over-the-door alarm by January 1, 2020.

38.1 13.00-1.00-38.01 Corridor Doors 38.1 Are all components of the over the door alarms free of anchor points? (Added Sept 2020) Over-the-door alarms must be inspected to ensure that they have been installed properly and do not have anchor points. See Patient Safety Advisory AL 20-02 Anchor point identified on The Door SwitchTM over-the-door alarm product in Veterans Health Administration (VHA) acute mental health units

MHEOCC for Locked Mental Health Units, General Criteria

&"Arial Narrow,Regular"Page &P of &N http://www.patientsafety.gov/alerts/AD11-02.pdfhttp://vaww.ncps.med.va.gov/Guidelines/alerts/Docs/AD12-01.pdfhttp://vaww.ceosh.med.va.gov/01FS/Pages/firesafety.shtmlhttps://vaww.sde.portal.va.gov/sites/fo/svcs/ectm/fis/wireless/Shared%20Documents/Important%20Docs%20for%20Sites/Installation%20Docs/Mental%20Health%20Areas%20Installation%20Guide.pdfhttp://vaww.office.ncps.med.va.gov/tools/pslog/edit.asp?id=937http://www.cooperindustries.com/content/public/en/wiring_devices/products/receptacles/residential/aspire/aspire_tamper_resistant_gfcis_9566tr_9569tr.html?_ga=2.252483850.203627272.1561398478-1792284201.1561398478 Sleeping Rooms

Note: break-away clothing rods are not allowed.

No rods of any kind should be allowed.

39 7.2.13.2.1.01 Door Locks Are locks on patient rooms free of anchor points and able to be open by staff? Also see 23 e. under the general criteria. (Added October 2010)

1. There is a requirement that all female patient rooms on mixed gender units have door locks. This is included in VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, as follows:

“All inpatient and residential care facilities must provide separate and secured sleeping accommodations for women. Mixed gender units must ensure safe and secure sleeping and bathroom arrangements, including, but not limited to door locks and proximity to staff” (p. 11).

3. For mental health units treating suicidal patients, it is important not to introduce new anchor points for hanging when adding locks to corridor doors to sleeping rooms. It is also critical to install door locks that can be opened by staff permitting them to enter the room and locking systems that do not prevent the patient from exiting the room (the exiting requirement does not apply to seclusion rooms). Either a manual locking system without anchor points or an electronic locking system that could be operated via a key fob or access card with rounded edges would be acceptable. Such an electronic locking system must also allow for staff access and have an override system that will allow for doors to be unlocked in the event of a power loss or system malfunction. Moreover, it is recommended that door locks not include slots in which cards are to be inserted or keyholes, as other materials may be placed in these slots and cause the locks to malfunction; rather, electronic sensors are recommended for electronic door locking systems, and cipher locks are recommended for mechanical locks. [Note: All locking systems must be in compliance with the requirements of the Life-Safety Code (National Fire Protection Association 101)].

4. In rare cases, the treatment team may determine that it is contraindicated to place a female patient in a sleeping room that has a corridor door that locks. In such instances, the reasons for not placing the patient in a locking room must be documented in the chart.

39.1 Sleeping Room Doors 39.1 a. Do all sleeping room doors have an over the door alarm?

39.1 b. Are all over the door alarms checked semi-annually to make sure they are still working properly? A May 10, 2019 memo from 10N states:

Effective January 1, 2020, all VA medical facilities with an acute mental health unit will be required to install door top alarms as recommended by the CFM design guide

41.2 7.2.13.2.3.02 Pillows and mattresses Are pillows and mattresses free of plastic, vinyl, or other materials that could be removed and used for suffocation or strangulation? Pillows and mattresses should not have covers that can be easily removed by the patient and used for suffocation. This requirement is consistent with eliminating plastic trash can liners (refer to question #35) and vinyl or plastic shower curtains (refer to question #59). Updated 2014

See Use of elastic-hemmed fitted bed sheets in mental health units AL 11-02 http://vaww.ncps.med.va.gov/Guidelines/alerts/Docs/AL11-02Elastic-hemmedFittedBedSheets.pdf

41.3 7.2.13.2.3.03 Sheets Are all fitted bed sheets (with elastic) removed from the units and replaced with either non-elastic fitted sheets or standard flat bed sheets? While bed sheets themselves can be used as ligatures, bed sheets with elastic are potentially more dangerous as ligatures than bed sheets without elastic. Elastic wrapped tightly around a neck may continue to remain tight and strangle the patient, even after the patient has passed out and stopped applying tension.

NOTE: This is specific to fitted sheets and is not intended to suggest that other items which generally do not have non-elastic alternatives (e.g. pajama pants, underwear, brassieres) be removed from the units.