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Based on observation, interview and record review, it was determined the facility failed to ensure care was given in a safe environment as evidenced by one (1) of ten (10) patients removing a small metal plate from the bottom of a chair and attempting to cut his/her wrist with this metal object (Patient #2).

The findings include:

Review of the facility's policies revealed no policy existed for this type of incident.

Review of the clinical record for Patient #2 revealed he/she was admitted 03/08/12 on a seventy-two (72) hour involuntary hold for expressing suicidal and homicidal ideations. His/her diagnoses included Adjustment Disorder and Mild Mental Retardation. The initial level of supervision was safety (must stay on the unit) with checks by staff every fifteen minutes and assault precautions. On 04/04/12 at 5:45 PM, Patient #2 was on support level supervision (could attend Recovery Mall for classes) and was being monitored during the day/evening every thirty (30) minutes. At this time, Patient #2 showed staff a piece of metal, ran to the enclosed porch, refused to give staff the metal, and verbalized intent to harm self with the metal object. Patient #2 cut the left thumb of the Mental Health Associate (MHA #1) caring for him/her when the sharp metal object was extricated from the patient. The record further revealed Patient #2 was placed in five-point restraints at 5:50 PM because he/she posed a risk to self and others.

Interview with Patient #2, on 04/06/12 at 4:16 PM, revealed on 04/04/12, the patient was on the porch, turned a chair over and saw a piece of metal on the chair. He/she stated it was easy to remove from the chair, and it had a sharp edge when it came off the chair. He/she further revealed there was an intention to harm self by cutting his/her left wrist with the sharp metal object, but was prevented from doing so by staff intervention.

Interview with MHA #1, on 04/06/12 at 3:15 PM, revealed she did cut her left thumb when retrieving the sharp metal object from Patient #2. She stated the metal object was taken off the bottom of a chair on the porch and had a number on it. She had seen metal plates like it on other chairs, and it appeared to be an inventory number. She further revealed Patient #2 was on the porch looking for something to harm self, and he/she saw the metal plate on the bottom of the porch chair. Patient #2 pulled it off and attempted to cut his/her left wrist. She further revealed Patient #2's left wrist was reddened, but no skin breakage occurred. Patient #2 was not harmed.

Interview with the Hospital Administrator, on 04/10/12 at 4:25 PM, revealed most every piece of furniture the State of Kentucky owned in the facility had an inventory number attached to it. She also stated there could be different forms of this attachment, such as metal plates, plastic stickers, etc.

Observation of the two (2) chairs in the Gragg 2 Interview Room, on 04/06/12 at 4:45 PM, revealed metal plates with a number etched on them on the bottom of each chair. This metal plate, on one chair, was easily removed.