HospitalInspections.org

Based on observation and interview, the facility failed to ensure care in a safe setting on a unit with 22 patients, 16 of which were on suicide precautions, as shown by the presence of four sharpened 'golf' pencils left unattended on a table in the common dayroom.

Findings included:

Review of facility policy ID #15183010 titled "Safe & Functional Environment", last reviewed 7/2020, showed the facility will ensure that areas used by patients are maintained to promote patient safety.

Observation on 10/29/24 at 12:10 pm of facility's Maples unit revealed there were four 'golf' type of pencils left unattended on one of the tables patients use on the unit's common area dayroom. These wooden pencils had sharpened tips capable of inflicting self-harm including puncturing, cutting, and swallowing. They also posed a risk for patients to use as a weapon to injure others.

Record review of facility's current census on the Maples unit for the day showed there were a total of 22 patients presently residing on the unit. Of these, 16 patients were currently on suicide precautions and one was on assault precautions.
During this observation time, the following staff were present and also observed the pencils present on the table: DQS-Staff #A, QC-Staff #C, RN-Staff #D.

In an interview at the time of these findings, Staff #A acknowledged the pencils were a safety hazard and subsequently removed them from the table, then informed other staff to ensure they monitored the area for sharp objects.