HospitalInspections.org

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Based on interview and review of documentation and medical record it was determined that the hospital's governing body failed to ensure that the rights of all patients in the psychiateic unit were protected and that their safety was assured.


This failure placed all patients at risk of potential injury from items used for craft activities that could potentially be used as harmful implements and resulted in actual harm for 1 of 10 patients (#1) when s/he use a pencil to stab his/her eyes.



Findings include:



As evidenced in the findings detailed in this report, the cumulative effect of the systemic problem resulted in the hospital failing to protect the safety of Patient #1 and failing to implement corrective measure where necessary to assure the safety of all patients in the psychiatric unit.


Failure to assure the safety of Patient #1.
Reference Tag-A0144
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Based on observation, interview and review of documentation, the hospital failed to ensure a safe environment in the secured psychiatric unit. This failure placed all patients at risk of potential injury from items used for craft activities that could potentially be used as harmful implements and resulted in actual harm for 1 of 10 patients (#1) when s/he use a pencil to stab his/her eyes.


Findings include:


All interviews and observations were conducted on 2/16/2016.



Patient #1 was admitted to the psychiatric unit on 2/13/16 for evaluation and treatment of mental health disorders. The patient did not have a known history of self-harm.



Documentation indicated Patient #1 was observed every 15 minutes on 2/14/16. It was also noted the patient kept his/her head covered with bed linens. at 5:00 p.m. a Registered Nurse (RN) noted blood on the patient's linen. The patient stated s/he had a bloody nose. The patient would not allow the RN to examine him/her.



At 11:20 p.m. the patient notified the RN that his/her eyes are swollen but refused to allow an examination. Security was called for a "stand by" while the RN examined the patient. Patient #1 told the Registered Nurse (RN), "I stabbed my eyes with a pencil."



The staff members then searched the patient's room and found "several pieces to a pencil with blood on it."



The patient was transferred to the emergency department and subsequently transferred out to a regional specialty hospital to evaluate and treat the eye injury.



During an interview with the staff members on the psychiatric unit it was learned Patient #1 obtained a colored pencil from the craft activities supplies. Observation of the common area in the psychiatric unit took place at 12:00 p.m. The patients were eating lunch and staff members were available in the room. Several patients were walking independently about the unit and outside the common area. On top of a cart located against a wall were containers of pencils, several long-handled brushes were there and other items used for craft activities. The items were not secured.



During this observation of the unit with the unit supervisor (RN #1) it was disclosed the pencils and brushes were to be secured when not in use.



It was learned that a unit guideline had been developed related to safety in a therapeutic milieu. It addressed checking in and checking out items such as hair dryers. The guideline did not address checking in or checking out craft items.