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A. Based on review of Hospital policy, observation and staff interview, it was determined that the Hospital failed to ensure all adolescent unit bathrooms were kept locked for patient safety.

Findings include:

1. The Hospital policy titled, "Nursing Responsibility for Patient, Visitor, and Employee Safety" was reviewed on 11/17/08 at 11:15 AM. The Policy required, "Nursing Department Staff shall assist in ensuring that patients... are protected from unsafe ...condition. ...Emphasize the need to maintain patient safety at all times... Nursing Safety forms (Clinical/Safety walking Rounds)...." The Clinical and Safety Walking Rounds sheet included "bathroom doors locked (Youth Services)" as an indicator.

2. A tour of the 2 South Adolescent Boys unit on 11/17/08 between 9:20 and 11:10 AM. Room 278 bathroom door was not closed or locked. Room 279 bathroom door could not be locked due to the latch being filled with tissue paper, preventing the lock to latch.

3. The Nurse Manager for the Adolescent boys was interviewed on 11/17/08 at 10:00 AM, during the tour. The Manager stated that all bathrooms doors remain locked and are only unlocked for patient use.





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B. Based on observation, staff interview and review of Hospital policies, it was determined that the Hospital failed to ensure that patients are provided care in a safe setting.

Findings include:

1. A unit tour of 1 west was completed on 11/17/08 at 9:15 AM. Eight (8) sharpened colored pencils were found laying under a t-shirt on the shelf in room 151. The patient (Pt #1) residing in this room was noted to have an admitting diagnosis of Aggressive and Violent Behavior.

2. An interview with the Director of Social Services was conducted on 11/17/08 at 9:25 AM. It was stated that "the pencils should not be in the individual patient rooms".

3. Hospital policy number RI III (306) "Unit Contraband List" includes " The following items are considered contraband; if found, remove from patient's possession immediately....23. Items that can be used as weapons...27. Pens and paperclips".

4. The above findings were conveyed to the Director of Social Services during an interview on 11/17/08 at 10:30 AM.

A. Based on review of Hospital policy, and staff interview, it was determined that the Hospital failed to ensure an agreement was place with an Organ Procurement Organization for organ donation.

Findings include:

1. The Hospital policy reviewed on 11/19/08 at 1:30 PM, titled "Organ Donation" required, "1. ...unexpected deaths may occur and ...reported to ...ROBI....2. The organ Procurement Organization will obtain the donation consent...."

2. A request for the OPO agreement was made during an interview with the Chief Nursing Officer (CNO), on 11/19/08 at 1:30 PM. The CNO was unable to provide the OPO agreement.

3. The above findings were conveyed to the CNO during interview on 11/19/08 at 1:45 PM.