Henry Mcconnell has been an administrator surveyor with the joint oomfmission for five years currently serves on a survey team reviewing a large midwestern tertiary care facility.

Case Study ………… . ……… Henry Mcconnell has been an administrator surveyor with the joint oomfmission for five years currently serves on a survey team reviewing a large midwestern tertiary care facility. The sugible going well, and he and the nurse member of the team are visiting the patient care areas of the facility is chief operating officer (COO) and the chief nursing officer (CNO) accompany the two surveyors to ysthe nursing units. They decide to visit the inpatient psychiatric unit. This particular inpatient psychiatric unit cares for people with psychotic and other severe er disturbances. Many of the patients on the unit frequently suffer hallucinations. Others have had prof pital episodes of violence toward others. The unit is known in psychiatric medicine as a "locked fachos meaning that special access is necessary to enter or exit the unit. As Mcconnell and his fellow nurse surveyor approach the unit with the COO and the CNO, the con comments on the level of acute psychiatric patients that the institution commonly houses in the unit points out that the double doors are made of metal with wired glass windows and that the doors are locked from both sides. She makes a production of getting out her door access card to the unit so that they co enter, making sure that the two surveyors see that the doorknobs will not open the doors and that one cor enter only with an access card. After they all pass through the doors, she turns around to show them the the doors have closed securely behind them. They then turn to go onto the unit to do the review. The COO and the CNO walk carefully out in fro of the surveyors toward the nursing station, the surveyors following a little way behind. One of the things Mcconnell observes is a three-foot-long, red-handled firefighter’s axe located about five feet in the doorway and up near the ceiling. Case Study Questions 1. The axe in this patient care setting is an obvious issue. Why might it still be there? 2. What common characteristic of healthcare organizations are exhibited in this case? 3. How could a potentially dangerous situation such as this be avoided? . . . . . . . . . . . . . . . . .