HospitalInspections.org

Based on observation, interview and record review, the hospital failed to maintain the patients' rights to personal privacy when, as part of the hospital's corrective action following an alleged sexual encounter between patients, staff were directed to visualize all patients while in the bathroom taking a shower in a shower stall with no curtain available for privacy. This failure had the potential to impact any of the 18 patients on the unit during the time of the survey.
Findings:

Review of the policy and procedure titled, "Patient Rights, Responsibilities, Complaint, and Grievance Process" revealed, in part, patients shall receive care, treatment and services with compassion and respect that fosters dignity, autonomy, positive self-regard, civil rights and the involvement of the patient, or when appropriate, the patient's representative in care.

Review of the policy and procedure titled, "Special Precautions" revealed, in part, special precaution procedures can be initiated by physician or nursing staff when a patient is considered to be at imminent risk for harm to self, other or property, or for those who need an increased level of observation and/or precautions for other specified reasons. Routine or Level 3 observations every 15 minutes. 3. Staff should maintain visual and verbal contact sufficient to monitor the patient's condition on a frequency level as order by the physician (every 15 minutes). Rounding should be staggered as to not be predictable by patients. 5. Day rooms, hallways and unit common areas should be supervised by staff during unstructured times when patients are present. Special every 10 minute Precautions (observations every 10 minutes) - This precaution should be provided for patients when it is deemed the patient should be more closely observed than every 10 minutes.

Review of a document titled, "huddle script" dated 09/16/2022 revealed, in part, that all patients must be visualized upon rounds regardless of their observation level. This means that if a person on Q15 or Q10 minute rounds is in the shower, the observer must see that person in order to complete the Behavior Observation Record.

A tour of unit 'a' on 10/12/2022 at 1:23 p.m. revealed semi-private rooms with 1 bathroom located in each room. The doors to the bathrooms were structurally modified to eliminate ligature risks allowing for staff to observe patients from outside of the bathroom doors. Further observation revealed shower stalls in the bathrooms with no shower curtains to allow for privacy while performing hygiene. The patients are able to be visualized by staff members unclothed while showering.

In interview on 10/12/22 at 1:10 p.m., S1RN1indicated part of the plan of correction the facility took related to the alleged sexual encounter between patients included staff directly observing patients while in the shower. S1RN1 indicated these observations may include female staff members observing male patients as well as male staff members observing femaled patients. S1RN1 further indicated the hospital did not use shower curtains in the bathrooms.

Based on observation and interview the facility failed to provide care in a safe setting. This deficiency was evidenced by toilets with ligature risk points at the hinged toilet seat for 13 (A1-A7 and B1-B6) of 13 toilets located on the unit for patient use. This deficient practice had the ability to affect any of the 32 patients in the facility and any new admissions.

Findings:

On 10/12/2022 a tour of the unit bathrooms revealed toilets with hinged seats that could be used as a ligature point in all patient rooms A1-A7 and B1-B6.

In an interview on10/12/2022 at 1:23 p.m. S1RN1 verified the patient bathroom toilet seats could be a potential for ligature points.