HospitalInspections.org

Based on observations and interviews, the facility failed to ensure that patients received care in a safe environment on 2 of 2 units. This failure resulted in patients on the Psychiatric Intensive Care Unit and Interim Psychiatric Unit having access to items that could be used for self-harm: rubber gloves and a set of keys.

Findings included:

During a tour of the fourth floor on 3/24/2021 at 1:45pm two adjacent units were visited: The Psychiatric Intensive Care Unit (Side A) and the Intermediate Psychiatric Unit (Side B). It was observed on the Psychiatric Intensive Care Unit that Staff S (Mental Health Technician - MHT) was making rounds on the hallway. He moved from one end of the hallway to the other with his clipboard, making the 15-minute rounds. He was the only staff member on the hallway. Other staff were in the nurse's station at one end of the hallway. There was a small table and three chairs at the far end of the hallway away from the nurse's station. Two boxes of rubber gloves were on the seat of one of the chairs. There was a small trash can next to the table. When the lid of the trash can was lifted, several used rubber gloves were found among the trash. A jacket was on the back of one of the chairs. When the jacket was lifted by Staff E (RN), metal jingled in the pocket. Staff S found a set of keys in the pocket.

It was observed on the Intermediate Psychiatric Unit that there was a small trash can in the hallway. When the lid of the trash can was lifted, several used rubber gloves were found among the trash.

In an interview with Staff S (MHT) and Staff E (RN) on 3/24/2020 at 2:00pm, they stated the gloves should be kept in a secure area and should not have been left unattended on the unit. They both stated the rubber gloves were not to be disposed in the trash receptacle in the hallway. They identified this as a patient safety concern. Staff T stated the jacket belonged to another MHT (Staff T) who was not on the unit. Staff S concluded by saying that he did not know the keys were in the jacket pocket until Staff E lifted the jacket and he heard metal jingle. Staff S and Staff E both stated the keys should not have been left in the hallway on the unit by Staff T.

In an interview with Staff T (MHT) on 3/24/2020 at 2:10pm, he stated the jacket and keys belonged to him. He also stated he should not have left the keys on the unit because they could be used as a weapon, causing harm to patients and staff members.

Record review of the Nursing Unit Census dated 3/24/2021 showed no patients on suicide precautions. Seven patients had been admitted with suicidal ideation (Patients # 11, 12, 13, 14, 15, 16, and 17) but were no longer experiencing suicidal thoughts. Review of these patient's medical records (suicide reassessments and physician's orders) showed that they were not experiencing suicidal thoughts.

Record Review of policy BH03, Management of Hazardous Items, revised 6/23/2020, showed: "... High risk hazardous items ... sharp objects ... gloves."