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Environmental Suicide Risk Assessment Report

Western State (Building 17 - C7, 8, 9)Lakewood, WA

7/2/2018

Western State (Building 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Space Observed Potential Suicide Risk RiskClassification Potential Mitigation ActivitiesRoom

BH Patient Room Other attachment points (Ligature):These rooms are a carbon copy of patient rooms onC8 and C9.Clothes LockerSprinklerVentWhite boards, etc.

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-101, 105, 107, 111,115, 121, 102, 106, 108,112, 134, 138, 140, 144,137, 133

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

HC7-102, 137

BH Patient Bathroom Door handle, loose (Ligature)BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation

HC7-103, 109, 123, 104,110, 116, 136, 142, 135

BH Patient Bathroom Faucet, not ligature proof (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation

HC7-103, 109, 123, 104,110, 116, 136, 142, 135

BH Patient Bathroom Fire strobe and sprinkler (Ligature)BH Dedicated Space Provide slanted top enclosureOne-to-one observation

HC7-103, 109, 123, 104,110, 116, 136, 142, 135

BH Patient Bathroom Other attachment points (Ligature):Hand dryer not flush to wallVent

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-103, 109, 123, 104,110, 116, 136, 142, 135

BH Patient Room Door handle, loose (Ligature)BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation

HC7-105, 108, 112, 138

BH Shower, Corridor Other attachment points (Ligature):Hand dryerLight not tamper proof

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-113, 119, 139, 143

BH Shower, Corridor Other attachment points (Ligature):Sprinkler

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-113, 119, 139, 143

BH Shower, Corridor Shower head (Ligature)BH Dedicated Space Replace with ligature-resistant shower headOne-to-one observation

HC7-113, 119, 139, 143

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 2

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Tub Room, Corridor Other attachment points (Ligature):Same as all other tub rooms on C8 and C9Being used for storage not patient access

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-114

BH Exam Room Other attachment points (Ligature):Medical equipment and cartOxygen tanks and holder with chainSupply shelfCabinet hingesWall mounted hookCurtain glide across roomLay in ceiling not secured

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC7-118

BH Exam Room Other attachment points (Ligature):View boxWooden holderWindow top not covered

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC7-118

BH Exam Room Other attachment points (Ligature)BH Common Area Remove attachment points as feasibleOne-to-one observation

HC7-118

BH Exam Room Other attachment points (Ligature):Medical equipment and cartOxygen holder chains and hookWall HookCabinet hingesSink hardware standardElectrical conduitWall mounted holdersOto scope & Blood PressurePaper towel dispenserView boxGlove holdersLay in ceiling,Ceiling mounted curtain glideMetal shelves

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC7-118

BH Seclusion Room Bed, BH, with attachment points for restraints(Ligature)

BH Dedicated Space Remove the restraint attachment points, if not in useOne-to-one observation

HC7-120, 122

BH Seclusion Room Other attachment points (Ligature):SprinklerVent

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-120, 122

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 3

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Conference Room Ceiling, lay-in (Ligature, Contraband) and sprinklerBH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group

MC7-125

BH Conference Room Other attachment points (Ligature):Fan mounted on wallMetal lockerWhite board

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC7-125

BH Activity Room Door handle, and hinges standard (Ligature)BH Common Area Replace with ligature-resistant door handleDirect observation of group

MC7-126

BH Activity Room Fire strobe (Ligature):Fire strobe and sprinkler

BH Common Area Provide slanted top enclosureDirect observation of group

LC7-126

BH Activity Room Other attachment points (Ligature):Convex mirrorLay in ceiling

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC7-126

BH Conference Room Ceiling, lay-in (Ligature, Contraband) and sprinklerBH Common Area Replace with hard ceilingGlue or clip tiles in placePlace motion sensor above ceilingDirect observation of group

MC7-127

BH Conference Room Other attachment points (Ligature):TV cabinet holes on side and top plus white powercordWhite board

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC7-127

BH Conference Room Pictures, artwork, boards, wall mounted (Ligature,Harm):White boardsPictures on wall

BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group

MC7-127, 125

BH Patient Room Other attachment points (Ligature):CPAP cabinet

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC7-133, 112

BH Laundry Room Other attachment points (Ligature):Sink hardware standardPaper towel dispenserCabinet hinges

BH Common Area Prohibit patient accessProvide ligature-resistant devices or coversRemove attachment pointsProhibit patient accessDirect observation of group

HC7-146

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 4

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Laundry Room Other attachment points (Ligature):SprinklerDoor stop

BH Common Area Prohibit patient accessProvide ligature-resistant devices or coversRemove attachment pointsProhibit patient accessDirect observation of group

HC7-146

BH Corridor Fire annunciator and sprinkler cage (Ligature)BH Common Area Provide slanted top enclosureOne-to-one observation

HC7-Patio

BH Corridor Other attachment points (Ligature):Window Iron worksFoos ball tableCamera conduit

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC7-Patio

BH Corridor Other attachment points (Ligature):Water valve boxDoor hinge standard

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC7-Patio

BH Corridor Other attachment points (Ligature):Convex mirrorsBell

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC8 Corridor

BH Patient Room Other attachment points (Ligature):Hole in door frame

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8- 210A

BH Corridor Other attachment points (Ligature):Wooden wand boxFire alarm strobeWater fountainTelephoneTV floor cabinet: lockSink hardware standardPaper towel dispenser

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC8- Lobby

BH Corridor Fire strobe (Ligature) and sprinkler cage.BH Common Area One-to-one observation HC8- Patio

BH Corridor Other attachment points (Ligature):Window Iron worksFoos ball tableCamera conduit

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC8- Patio

BH Corridor Other attachment points (Ligature):Metal plates

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC8- Patio

Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.

Western State (Building 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 5

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Patient Room Bed, medical (Ligature)BH Dedicated Space Use hospital beds only if medically necessaryOne-to-one observation

HC8-201

BH Patient Room Other attachment points (Ligature):Grab bars not flush to wall, has gap

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-201

BH Patient Bathroom Faucet (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation

HC8-201, 202, 204, 208,207, 236, 242, 235

BH Patient Bathroom Fire strobe and conduit (Ligature)BH Dedicated Space Provide slanted top enclosureOne-to-one observation

HC8-201, 202, 204, 208,207, 236, 242, 235

BH Patient Bathroom Other attachment points (Ligature):Paper towel dispenserHand dryer not flush to the wallVent243: Wood on the wallLight not tamper proof

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-201, 202, 204, 208,207, 236, 242, 235

BH Patient Room Door swing, inward (Barricade)BH Dedicated Space Reverse door swingProvide barricade-resistant doorsOpen door policy enforcementOne-to-one observation

HC8-201, 205, 207, 211,202, 206, 208, 212, 234,238, 240, 244, 237, 233

BH Patient Room Other attachment points (Ligature):Clothes locker shelvingDoor handles looseDoor stop

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-201, 205, 207, 211,202, 206, 208, 212, 234,238, 240, 244, 237, 233

BH Patient Room Other attachment points (Ligature):Door handle looseCabinet "L" bracket

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-202

BH Patient Room Other attachment points (Ligature):Door sealed with screws

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-204

BH Patient Room Sprinkler heads, standard (Ligature):Bathroom door strike plate loose

BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation

HC8-205

BH Patient Room Other attachment points (Ligature):Access doorSprinkler

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-208

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 6

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Patient Room Other attachment points (Ligature):Door lock loose

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-209A

BH Shower, Corridor Other attachment points (Ligature):Fire alarm strobeSink faucetPaper towel dispenserSprinklerVentLight not tamper proof

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-213, 219, 239, 254,260

BH Tub Room, Corridor Other attachment points (Ligature):This room is used for storage.Apollo tubCabinet hingesSprinklerMagnetic door hold opens on wall and doorPaper towel dispenserHand sanitizerSink hardwareGrab bars-toilet gaps not flush to wallCommode seat coverVentLight fixture corners not flush to ceiling

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-214

BH Patient Room Other attachment points (Ligature):Fire alarm strobe and conduitSprinklerHand dryer not flush to wallCommode pipe

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-216

BH Exam Room Other attachment points (Ligature):Wall hook with sledCurtain glide mounted with wood across ceilingView box and Wooden holder

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC8-218

BH Exam Room Other attachment points (Ligature):Medical equipment and cartOxygen holder chains and hookCurtain rail mountLay in ceiling

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC8-218

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 7

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Seclusion Room Other attachment points (Ligature):SprinklerVentDoor frame window

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-220

BH Seclusion Room Bed, BH, with attachment points for restraints(Ligature)

BH Dedicated Space Remove the restraint attachment points, if not in useOne-to-one observation

HC8-220,222

BH Group Room Other attachment points (Ligature):White boardsWooden cabinet hingesMetal cabinet lock and latch

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC8-225

BH Group Room Other attachment points (Ligature):Fire alarm strobeWindow top uncoveredDoor handle looseSprinklerConvex mirror not flush to ceilingDoor hold open magnets on door and wallWhite panel board

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC8-226

BH Patient Room Window, top not covered (Harm)BH Dedicated Space Seal windowOne-to-one observation

HC8-233

BH Patient Room Other attachment points (Ligature):Door handle key lock looseBathroom door hinge cap missing

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-234, 238

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

HC8-240

BH Patient Room Other attachment points (Ligature):Door handle looseDoor stopSprinkler

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-240, 244, 237, 233

BH Patient Room Diffuser, wide openings (Ligature)BH Dedicated Space Provide cover with small openingsOne-to-one observation

HC8-244

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 8

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Laundry Room Other attachment points (Ligature):Washer water connectionsCabinet locks and hinges

BH Common Area Prohibit patient accessProvide ligature-resistant devices or coversRemove attachment pointsProhibit patient accessDirect observation of group

HC8-246

BH Laundry Room Other attachment points (Ligature):Convex mirrors not flush to ceilingWindows not covered at top

BH Common Area Prohibit patient accessProvide ligature-resistant devices or coversRemove attachment pointsProhibit patient accessDirect observation of group

HC8-246

BH Shower, Corridor Other attachment points (Ligature):Door lock is loose

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC8-246

BH Group Room Fire strobe and Pendent alarm box (Ligature):Nurse call lights

BH Common Area Provide slanted top enclosureDirect observation of group

LC9- Corridors

BH Recreation, Indoor Other attachment points (Ligature):Window barsFoosball tableExercise bikeFire strobe and sprinkler cover

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC9- Patio

BH Recreation, Indoor Other attachment points (Ligature):Water valve coverMetal cover

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

HC9- Patio

BH Patient Room Clothes locker panels and shelves (Ligature)BH Dedicated Space Remove doors and hingesOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Room Diffuser (vent), wide openings (Ligature)BH Dedicated Space Provide cover with small openingsOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Room Door handle, loose and door stop (Ligature)BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Room Door swing, inward (Barricade)BH Dedicated Space Reverse door swingProvide barricade-resistant doorsOpen door policy enforcementOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 9

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Patient Room Other attachment points (Ligature):Window top not coveredWhite board

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Room Other attachment points (Ligature):Cabinet hingesBulletin boards

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Room Sprinkler heads (Ligature)BH Dedicated Space Replace with ligature-resistant sprinkler headsOne-to-one observation

HC9-301, 305, 307, 311,315, 321, 302, 314, 334,338, 340, 344, 341, 337,333

BH Patient Bathroom Door handle, loose(Ligature),Access panels

BH Dedicated Space Replace with ligature-resistant door handleOne-to-one observation

HC9-303, 317, 323, 316,304, 336, 342

BH Patient Bathroom Faucet, (Ligature)BH Dedicated Space Replace with ligature-resistant faucetOne-to-one observation

HC9-303, 317, 323, 316,304, 336, 342

BH Patient Bathroom Fire strobe and conduit (Ligature)Sprinkler not recessed

BH Dedicated Space Provide slanted top enclosureOne-to-one observation

HC9-303, 317, 323, 316,304, 336, 342

BH Patient Bathroom Other attachment points (Ligature):Hand dryer not flush to wallPaper towel dispenser

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-303, 317, 323, 316,304, 336, 342

BH Shower, Corridor Other attachment points (Ligature):Lights not tamper proofVent

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-313, 319, 339, 343,354, 350

BH Shower, Corridor Other attachment points (Ligature):SprinklersSpeakers not flush to ceiling

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-313, 319, 339, 343,354, 350

BH Shower, Corridor Other attachment points (Ligature):Paper towel dispenserHand sanitizer

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-313, 319, 339, 343,354, 350

BH Tub Room, Corridor Other attachment points (Ligature):Being used for storage only and has same findings asall other tub rooms.

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-314

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 10

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Exam Room Other attachment points (Ligature):Medical equipment and cartOxygen tanks and holder with chainSupply shelfCabinet hingesWall mounted hookCurtain glide across roomLay in ceiling not secured

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC9-318

BH Exam Room Other attachment points (Ligature):View boxWooden holderWindow top not covered

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC9-318

BH Exam Room Other attachment points (Ligature):Cabinet hingesSink hardware standardPaper towel holderHand sanitizer

BH Common Area Remove attachment points as feasibleOne-to-one observation

HC9-318

BH Seclusion Room Other attachment points (Ligature):VentElectrical outlet screws not tamper proofSpeaker not flush to ceiling

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-320, 322

BH Group Room Door handle and hinges, standard (Ligature) anddoor handle loose

BH Common Area Replace with ligature-resistant door handleDirect observation of group

MC9-326

BH Group Room Fire strobe (Ligature)BH Common Area Provide slanted top enclosureDirect observation of group

LC9-326

BH Group Room Other attachment points (Ligature):Windows not covered at topPool cue holder-wooden

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-326

BH Group Room Pictures, artwork, boards, wall mounted (Ligature,Harm)

BH Common Area Secure flush to wall with tamper-resistant screwsUnbreakable glass or acrylicDirect observation of group

MC9-326

BH Patient Bathroom Door, Screwed shut on both sides (Ligature)BH Dedicated Space Replace with ligature-resistant door(not acceptable in VA, MA, FL)Over-door alarmOpen door policy enforcementOne-to-one observation

HC9-335, 309

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 11

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Patient Room Other attachment points (Ligature):Door window frame gapRefrigerator handles and lock

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-338

BH Patient Room Other attachment points (Ligature),Convex mirrors

BH Dedicated Space Provide ligature-resistant devices or coversRemove attachment pointsOne-to-one observation

HC9-338, 307, 320, 321,Corridors

BH Laundry Room Other attachment points (Ligature):Same as all other laundry rooms:Washer connectionsSink hardwareCabinet hingesLay in ceilingWindow top not covered

BH Common Area Prohibit patient accessProvide ligature-resistant devices or coversRemove attachment pointsProhibit patient accessDirect observation of group

HC9-346

BH Activity Room Other attachment points (Ligature): Same findingsas other rooms:Door handle looseCabinet hingesSprinklerWindow topWhite boardsCounter "L" brackets

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-350

BH Group Room Other attachment points (Ligature):Paper towel holderSink hardware standardHand sanitizerSprinkler

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-353

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

MC9-353, 325, 323

BH Group Room Other attachment points (Ligature):Pencil sharpenerWindow top not coveredWhite board

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-353, 325, 323

BH Group Room Other attachment points (Ligature):White boardTV/monitor cabinet mounted the wrong direction

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-Corridors

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

Page 12

Space Observed Potential Suicide Risk Potential Mitigation Activities RiskClassification Room

BH Group Room Other attachment points (Ligature):Wooden boxes wall mounted

BH Common Area Provide ligature-resistant devices or coversRemove attachment pointsDirect observation of group

MC9-Corridors

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 17 - C7, 8, 9)Lakewood, WAEnvironmental Suicide Risk Assessment Report — 7/2/2018

High

Medium

Low

General/Acute Care

BH CommonArea

BH DedicatedSpace

RISK

CLASSIFICATION

3

24

18

1 2 3

4 5 6

7 8 9# Findings: 57

# Findings:

# Findings:

# Findings: BEHAVIORAL HEALTH SUICIDE RISK MATRIX EXPLANATION

We have modified The Joint Commission’s SAFER Matrix to reflect suicide risk by plotting thelikelihood of harm (H=high, M=medium, L=low) on the Y axis against the type of setting on the X axis.The setting itself may determine the likelihood of harm of some risks. The number of findings in aparticular box in the matrix is represented by the number in the upper right corner of the box.

All suicide risks would be scored by The Joint Commission at EC.02.06.01 EP 1.

Types of settings are as follows:

Behavioral Health Dedicated Space: This is the highest risk space in areas dedicated to behavioralhealth, whether in an inpatient unit or dedicated space in an emergency department. Dedicated spaceincludes patient rooms and corridors. Patients in these areas may not always have direct supervision.All risks in these areas are expected to be removed or mitigated with one-to-one observation.

Behavioral Health Common Areas: These are areas within dedicated behavioral health units in whichpatients are not without supervision, such as dining areas, group rooms, day rooms, etc. Risks in theseareas are to be documented and removed or mitigated as feasible.

General/Acute Care Areas: These are areas of the organization that are typically used by the non-behavioral health population, such as a general medical/surgical unit, intensive care unit, or a typicalemergency department treatment room or bay. Risks in these areas are to be identified and those risksthat are removable must be documented and removed when the space is occupied by a behavioralhealth patient. All remaining risks are to be mitigated by one-to-one observation.

NOTE: In outpatient behavioral health settings, patients are expected to be screened as to theappropriateness of the setting, therefore suicide risks are not scored in these settings.

Confidential and privileged communication is not to be used without the permission of the author. The information contained in this report is for the express purpose of aiding the organization in its own self-assessment activities, and is a componentof that self-assessment. Self-assessments have no direct impact on the official findings or conclusions of The Joint Commission, or CMS, whether done by the organization or third party consultants, and may not prevent all suicide attempts.

229 Whitney Drive Barrington, IL 60010 mslhealthcare.com Office : 888 951 1114 Fax : 888 951 1117

Thank you for partnering with RPA and MSL Healthcare. Please contact me if you have any questions.

Thank You!

General RecommendationsNote 1: this assessment is only for the foot print of the building and does not include the exterior or any attachment to the exterior of the building. The grounds and any structure on the groundsare also not included.

Note 2: S-3 is under remodel. 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, orunaccompanied. The organization will then determine their own risk for these areas.

Note 4: All elevator vestibules that patients access have in common: door bell, fire alarm and conduit, sprinkler head, some have a wall mounted phone with cord, door handle, and exposed doorclosure and hinges.

Note 5: All TV consoles have the same issues with the door hinges, door latch and lock, and strip across the top of the door.

Note 6: All patient rooms have the same issues with the clothes locker: long front panel, shelves have gaps, lower smaller shelf can be removed and used as a weapon as can the lower cabinetdoor, shelf brackets have gaps, top angle piece of locker is not flush to the wall, built in desk mounting brackets have gaps.

Note 7: Due to so many similar findings the pictures attached may not be the exact picture, but due to similarities represent the findings in kind.

Note 8: The following rooms have been in use: S7-211, S8-303, 305, 317, 314, 341, 301, 359, 351 not being used.

Troy Martintmartin@mslhealthcare.com