HospitalInspections.org

Based on Observation, Record Review and Interview, the facility failed to ensure a safe environment for 29 of 29 sampled patients on suicide precautions as evidenced by having unsafe toilets in rooms of 24 patients on suicide precautions and regular screws that were not tamper-resistant in 5 patient rooms on suicide precautions.

Findings included:

Observation on 6/3/19 at 9:30 AM of facility's Woman's Unit 6 revealed the following: In Patient #4's room, there were four electric outlet switch plates held in place by two regular flathead screws each, which were not tamper-resistant and a grab-bar in the shower secured by regular Phillip's Head screws, also not tamper resistant.

In Patient #5's room, there were five electric outlet switch plates held in place by two regular flathead screws each.

In Patient #6 and Patient #7's room (they shared the same room), there were four electric outlet switch plates, each secured in place by two regular flathead screws.

In Patient #8's room, there were four electric outlet switch plates, each held in place by two regular flathead screws.

Record review showed Patients #'s 4, 5, 6, 7, & 8 were all currently on Suicide Precautions.

Observation on 6/3/19 at 10:00 AM of facility's Unit 5 PICU revealed that all 13 rooms on the unit had toilets that where not flush with the wall, creating spaces between the toilets and walls which could potentially be used to tie-off bedsheets, clothing, or other articles, which posed ligature risks.

Record review showed there were seven patients currently on Suicide Precautions housed in these rooms; Patients #'s 9, 10, 11, 12, 13, 14 & 15.

Observation on 6/3/19 at 10:30 AM of facility's Adolescent Unit 7 revealed that all 11 rooms on the unit had toilets that where not flush with the wall, creating spaces between the toilets and walls which could potentially be used to tie-off bedsheets, clothing, or other articles, which posed ligature risks.

Record review showed there were currently 11 patients on suicide precautions; Patients #'s 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 & 32.

Observation on 6/3/19/at 10:45 AM of facility's Senior Adult Unit 4 revealed that all nine rooms on the unit had toilets that where not flush with the wall, creating spaces between the toilets and walls which could potentially be used to tie-off bedsheets, clothing, or other articles, which posed ligature risks.

Record review showed that six patients on the unit were currently on suicide precautions; Patients #'s 16, 17, 18, 19, 20 & 21.

In an interview on 6/3/19 at 11:00 AM, Staff #51 acknowledged that the non-tamper resistant screws and the toilets with spaces in back of them all posed potential self-harm hazards.