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Based on record review and staff interview, the facility failed to ensure that all patients using the community bathroom on the forensic unit were able to call for help if they needed it for 1 of 1 patients reviewed found with an injury (Patient #1.)

Findings:

On 8/26/2013, Patient #1 entered the community bathroom on the forensic unit. Thirteen minutes later, s/he was found unconscious by staff on the floor bleeding from a facial laceration in one of the stalls of the community bathroom on the forensic unit of the hospital. The cause of the injury was unknown. The patient was transferred to an acute care hospital where s/he remained in a coma for 67 days. S/he was then transferred to a skilled nursing facility where s/he died.

Staff interview on 12/20/2013 at 3 p.m. revealed that there was no call system in the forensic unit bathroom for patients to summon staff for assistance or help. There was no video monitoring, and staff did not regularly check the area for patient safety.

The facility did not provide a mechanism in the forensic unit community bathroom by which patients could call for help or assistance.