HospitalInspections.org

Based on observation, document review, and staff interview, the hospital's administrative staff failed to ensure repair was completed on all patient care toilets after 1 of 1 patients (Patient #1) disassembled a toilet lid and ingested a bolt from the toilet. Failure to ensure all toilets were repaired resulted in patients having access to toilets that could be disassembled which could possibly cause harm to a patient. The hospital identified a census of 43 patients on entrance.

Findings include:

1. Review of Patient #1's medical record revealed:

a. On 6/2/22 at approximately 5:00 AM, Patient #1 was admitted with a history of borderline personality disorder, factitious disorder (serious mental disorder in which someone deceives others by appearing sick, by purposely getting sick or self injury), foreign body ingestion, and chronic suicidally.

b. On 6/6/22 at 1:15 PM, Patient #1 stated that they had swallowed several bolts which they had removed from a hall toilet seat. On 6/6/22 at 2:30 PM, Patient #1 was transferred to the Emergency Department for evaluation.

2. During an interview on 7/12/22 at 11:20 AM, the Director of Plant Operations explained how the hospital had fixed the toilets so that no other patient could dismantle a toilet lid and potentially ingest a bolt.

3. Observations during an inpatient tour with the Director of Plant Operations on 7/12/22 at approximately 11:30 AM revealed a patient care toilet that had not been fixed. The Director of Plant Operations explained that they had immediately fixed the toilet in Patient #1's room and the hall toilet where the event had occurred, but they had not fixed any of the 70 other toilets that were accessible by patients.

4. During an interview on 7/12/22 at 2:15 PM, the Director of Risk Management confirmed the hospital had failed to fix all the toilets that were accessible to patients, and acknowledged it could be a potential safety risk for a patient.