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 Martintmartin@mslhealthcare.com