HospitalInspections.org

Based on observation, document review and interview, it was determined that the Hospital failed to ensure metal paint scrapers were not accessible to patients in the 5 South Behavioral Unit. This presented a potential safety hazard for 15 patients on census on the unit.

Findings include:

1. During an observational tour of the 5 South unit on 9/7/17 at approximately 11:15 AM, 4 metal scrapers used for applying and scraping dry wall spackling/caulking were observed on the floor, near a wall next to large garbage bin. The hallway was monitored by 2 stationary staff, standing at the end of the hallway approximately 30 feet away from the painters' equipment and supplies, while a 3rd staff was performing the every 15 minute patient monitoring. Three painters/contractors were spackling the walls using 3 other metal scrapers. One painter on the opposite wall had his back on the supplies and 4 metal scrapers on the floor, and the other two painters were in another hallway. The supplies and the 4 scrapers on the floor were not in full view of the painters. The 3 unsecured metal scrapers on the floor were accessible to patients walking in the hallway towards the dayroom.

2. The Facility policy titled, "Patients' Bill of Rights and Responsibilities" (Rev 7/17) required, "Patient's Rights-Exercise of Patient Rights...F the right to receive care in a safe setting."

3. The Contractor/Vendor/Intern/Volunteer/Student Orientation Acknowledgement Form" indicated, " ...In order to provide optimal quality of care to our patients, we required all contractors, vendors,...to review and acknowledge receipt of this important information....Safety: All health care providers are expected to provide a safe environment for patients..."

4. The Director of Behavioral Medicine (E #8) was interviewed while observing 5 South on 9/7/17 at approximately 11:15 AM. E #8 stated that there should be someone watching the equipment (scrapers) while not in use.

5. The Assistant Administrator (E #9) was interviewed on 9/8/17 at approximately 10:45 AM. E #9 presented four signed contractor (painter) orientation acknowledgement forms, stating the contractors (painters, workers) were made aware that they would be working in a behavioral unit needing additional precautions. E #9 stated that she expected the scrapers, supplies and equipment not being used to be locked and secured and not left unattended.

6. One of the three painters/contractors (Z #1) was interviewed on 9/8/17 at approximately 12:45 PM. Z #1 stated that they lock the metal scrapers in the rooms with them when painting a room. Z #1 indicated that while working in the hallway, they usually only have the scarpers that they use in their hands. Z #4 stated they are supposed to keep the scrappers with them or sucure/lock them if not in use. Z #1 stated they were told to watch their equipment and to lock them, especially in this unit (5 South-Behavioral unit).