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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

MAINTENANCE OF PHYSICAL PLANT

Tag No.: A0701

Based on review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to maintain the hospital environment in a manner that assured the safety and well-being of patients.

Findings Include:

Review of facility policy documented that "Environmental and safety checks are done with rounds. Check each patient room and bathroom for potential safety issues. Make sure that the hallways are clear and all doors are locked. Call maintenance for immediate problems (e.g. leaks, doors not locking, etc.) and report all environmental/safety concerns to the Registered nurse ... "

Observation tour on July 30, 2013, at 10:20 AM, of the Tower 7 psychiatric unit revealed the patient listed in MR7 was asleep in one of the unit's quiet/seclusion/restraint rooms. The room had a viewing window from the outside. The door to the room was locked from the outside. During the observation, EMP2 did not realize the room was locked and attempted to open the door with a key. EMP2 attempted several more times to unlock the door and each time was unsuccessful. EMP2 then requested assistance from EMP4 to open the door. EMP4 attempted several times to unlock the door and each time was also unsuccessful. The unit's housekeeper was in close proximity and also attempted to unlock the door and each time was unsuccessful. EMP2 attempted one more time to unlock the door, which was finally successful.

Review of MR7 revealed a progress note dated July 29, 2013, at 2:15 which indicated that the patient did not feel comfortable sleeping in the bedroom while another patient was also in the room. Patient slept in the solitary/quiet room instead and remained there.

Interview on July 30, 2013, at 10:30 AM, with EMP2 confirmed that it was not an appropriate practice for a patient to be in a quiet/seclusion/restraint room while the door was locked from the outside. EMP2 was not aware of this practice until it was observed during a tour of the unit.

Interview on July 30, 2013, at 1:45 PM, with EMP1 confirmed that it was not an appropriate practice for a patient to be in a quiet/seclusion/restraint room while the door locked from the outside. EMP2 was not aware of this practice until it was observed during a tour of the unit.