HospitalInspections.org

Based upon a review of facility documents, facility video, and employee interview (EMP), it was determined that the facility failed to ensure a safe environment by not maintaining patient privacy for two of two grievances reviewed (MR1 and MR12).
Findings include:
On 09/06/2023, a review of the complaint and grievances log revealed that on 04/06/2023, a patient (MR12) reported that on 4/5/2023, around 4:00, pm a certified nursing assistant (CNA) left a patient in shower without locking the door. During the investigative process the CNA confirmed that the shower door was left unlocked.
During an interview on 09/06/2023, at 10:30am, EMP3 was asked to explain the process for patient showers on the behavioral health unit. EMP3 stated, "the patient must be badged in by the employee. The employee unlocks the shower door and locks the patient in the shower. Patients can exit the shower, but no one can enter from the outside."
On 09/06/2023, a review of the complaint and grievances log revealed a report made on 09/02/2023, at approximately 7:00am, that in the evening of 09/01/2023, a female patient (MR1) heard a knock on the shower stall door, thought it was a staff member and opened the shower door. According to the report, the female patient stated that a male patient (MR2) "had come into my shower."
A review of the video recording of the shower area on the date and time of the above incident revealed the following:
On 09/01/2023, at 7:36 PM, EMP11 unlocked the shower ante room for a male patient (MR2) but did not accompany MR2 (to shower #3) to lock the shower for the patient.


On 09/01/2023, at 7:39 PM, EMP12 walked MR1 past shower room ante door into the area (to shower #2).


On 09/07/2023, at 12:05pm, EMP3 acknowledged that the correct process did not occur when EMP11 opened the door for MR2, which indicated the shower was not locked.


Multiple requests were made for written policies, procedures, protocols, processes, and/or staff education that would ensure safety and privacy for patients while showering on the behavioral health unit (since males and females utilize the same shower area). On 09/07/2023, at 12:05pm, EMP3 confirmed there were no written shower protocols or policies/procedures for showers on the behavioral health unit.