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Based on interview and record review, the facility's policy for "Room Assignments" did not accurately describe the actual process being used. This inconsistency could lead to an inadvertent unsafe room assignment by staff.

Findings included:


Review of facility policy tithed "Patient Rights," undated, showed: 'Basic Rights for All Patients' included: the right to a clean and humane environment; protection from harm, and privacy....

During an interview on 6/27/2024 at 2:15 PM with Staff-C, Quality Director, she provided an overview of the patient room assignment process. She said many factors are considered in appropriate patient room placement including choice of roommate. These elements include age; gender, history of sexually acting out ( victim; perpetrator); current diagnosis and condition & other factors. Staff-C said, for example: for adolescent roommates, practice is not to have a greater age gap than 3 years

The Quality Director said there was an electronic bed board located in intake and also in the nursing supervisor's office. Both bed boards are continually updated in real time.

When a bed was needed for a new admission , intake sends an SBAR (situation, background , assessment, communication ) document to the nursing unit with information about the patient. Intake also calls the Nursing Supervisor; they may suggest an open room on a unit. Intake asks the nursing supervisor if this room choice is appropriate ? It is the ultimately the nursing supervisor's decision and responsibility to approve room assignments. This is done in collaboration with the charge nurse on the unit. Staff C verified the SBAR communication was retained .

Record review of facility policy titled "Room Assignment " dated 5/2023, showed the policy to be incomplete and not consistent with facility's current practice. This was verified by Staff-C during the discussion and policy review.