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PALOMAR HEALTH DOWNTOWN CAMPUS
PATIENT RIGHTS: PRIVACY AND SAFETY
Tag No.: A0142
Based on observation and interview, the facility failed to ensure potential ligature points (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) were not present in the MHU of the facility.
As a result, there was the potential risk to the safety of the patients in the MHU.
Findings:
An onsite visit was made to the facility to investigate a self report of a successful suicide in the MHU.
A tour of the MHU was conducted on 12/20/17 at 1:50 P.M. with the DDR, DQPS, Facilities and DMHU.
There were multiple potential ligature points observed in patient rooms such as:
Headboards and footboards with hole openings, bed side rails, door hinges, door knobs, toilet piping, thermometers covered in square boxes, all of which could potentially have something looped through/over them.
In a room directly across from the nursing station (228), there was a bent metal paper towel holder, which created a loop access. This paper towel holder was bent by a patient who then looped a sheet/pillowcase through it to successfully hang himself.
The DQPS stated on 12/21/17 at 11:10 A.M. the facility was aware of the ligatures in the MHU.