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Based on observation, interview and record review, the facility failed to ensure a safe environment for one out of one sampled patients (Patient # 4) in Unit 1 who had been on suicide precautions, as evidenced by having an unsafe toilet in his room, and facility also failed to ensure a safe environment in the Children's Unit 8, as evidenced by having a ligature risk in the common boy's restroom.

Findings included:

Record review of facility policy titled "Levels of Observation" dated 3/19, stated that staff are to maintain a safe and therapeutic environment for all patients and all potential ligature risks must be removed from the environment.

Observation on 6/20/19 at 10:00 AM of facility's PICU Unit 1 revealed that the back of the toilet in the Patient #4's room (Room #110) had a thin metal cover placed over the back plumbing portion to prevent any potential ligature risk. However, upon feeling the bottom of the metal covering, there were two very sharp edges easily accessible which could have been used for cutting and self-harm.

In an interview on 6/20/19 at 10:05, CNO Staff #51 stated the sharp edges on the bottom of the metal toilet covering was a safety hazard.

Record review at time of survey of Patient #4's clinical records showed that he was on Suicide Precautions on 6/19/19 and had been housed in Room 110 during this time.

Observation on 6/20/19 at 10:30 AM of facility's Children's Unit 8's common boy's restroom, revealed an ADA grab bar in the shower that was not flush with the wall, creating an open space several millimeters wide, which could have been used as a ligature point. One side of the bar connection to the wall was covered with rust.

In an interview on 6/20/19 at 10:31, Staff #51 stated he recognized this as a problem for potential ligature risk and self-harm from the sharp metal edges.