Case Study Henry MecConnellhas been an administrator surveyor with the Joint Commission for five years. He currently serves on a survey team reviewing a large midwestern tertiary care facility. The survey is going well, and he and thenurse member of the team are visiting the patient care areas of the facility. The chief operating officer (COO) and the chief nursing officer (CNO) accompany the two surveyors to various nursing units. They decide to visit the inpatient psychiatric unit. This particular inpatient psychiatric unit cares for people with psychotic and other severe emotional disturbances. Many of the patients on the unit frequently suffer hallucinations. Others have had prehospital episodes of violence toward others. The unit is known in psychiatric medicine as a "locked facility," 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 COO comments on the level of acute psychiatric patients that the institution commonly houses in the unit. She 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 can enter, making sure that the two surveyors see that the doorknobs will not open the doors and that one can enter only with an access card. After they all pass through the doors, she turns around to show them that 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 front of the surveyors toward the nursing station, the surveyors following a little way behind. One of the first things McConnell observes is a three-foot-long, red-handled firefighter's axe located about five feet inside 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?