HospitalInspections.org

Based on observation and interview, the facility failed to provide a safe setting by not identifying and removing safety hazards, as shown by the presence of:

a. Rusty bolts protruding from the bases of toilets in 8 of 16 patient bathrooms (Rooms 104, 105, 107, 108, 200, 201, 205, 206), potentially affecting 16 patients;

b. 'Golf pencils' in 3 of 16 patient bedrooms (Rooms 108, 206, 207), potentially affecting 3 of 6 patients (Patient #4, #5, and Patient #6) that were on High-Risk Aggression/Homicidal Precautions, and;

c. A "Bic" pen left unattended on a table in Unit 200's common area dayroom, accessible to all 16 patients on the unit.

Findings included:


Review of facility policy initiated 1/26/12 titled "Patient Observation Rounds", last revised 11/2017, showed that either MHTs (Mental Health Technicians) or other staff member, such as nurses and therapists, will perform safety rounds at least every 15 minutes. In addition, Environment of Care (EOC) rounds are to be conducted every shift to identify and report any safety hazards, physical plant damage and contraband present.


A. Rusty bolts in bathrooms

Observation on 12/3/24 starting at 11:45 am of facility's Unit 100 showed the following; there were eight patient bedrooms, each with two beds and a shared bathroom. The bathrooms in rooms 104, 105, 107 and 108 had exposed rusty toilet bolts protruding upwards from the floor, all approximately one inch or slightly greater in length. These uncovered bolts helped secure the toilets to the floors. These bolts posed safety risks for patients who might accidentally step on them while bare-footed, causing puncture to the feet and potential infection. In addition, these bolts had the potential for patients to self-harm, as some of them had sharp edges.

Further observation on 12/3/24 at 12:15 pm of facility's Unit 200 showed similar findings: there were eight patient bedrooms, similar in layout to Unit 100. Each of these room had two beds with a shared bathroom. The bathrooms in rooms 200, 201, 205 and 206 also had the same type of exposed protruding rusty toilet bolts present.

In an interview on 12/3/24 with DCS-Staff #C at the time these findings, who was also present during observation of the toilet bolts, acknowledged they were safety hazards and should not have been present. In addition, after reporting the findings to Dir QAPI-Staff #A and CEO-Staff #B, both agreed the bolts were safety hazards and began facilitating efforts to remove the problematic risks.

B. Gold pencils and C. Bic pen

A tour on 11/3/2024, 11:45am-12:30pm, of Units 100 and 200 was conducted by Staff C, Director of Clinical Services. Observation of the commons area dayroom on Unit 200 at 11:55am, showed a BIC pen unattended on one of the large round tables.


Patient #4:

Observations of bedroom #108 on Unit 100 were conducted at 11:35am. Observations showed a placard to the right of the bedroom door with Patient #4 assigned to that room. Further observation of bedroom #108 showed a golf pencil unattended on the patient's bedside table.

Review of Psychiatric Evaluation by Staff H (MD) dictated on 11/30/2024, 1:47pm, and signed 12/1/2024, 3:59pm, showed Patient #4 was a 50-year-old female brought into the hospital by the police involuntarily.

Review of the Columbia-V4 Direct Admission Assessment Tool completed on Patient #4 by Staff G (RN) dated 11/28/2024, 10:34am, showed:
" History of assault/'threats toward police.
" Paranoid ideation, command hallucinations, and visual hallucinations.
" Aggression toward hospital staff.

Review of Nursing Admission Assessment by Staff J (RN) dated 11/30/2024, 7:30pm, showed Patient #4 to be loud and rambling. She was hostile, demanding, impulsive, threatening, and uncooperative with much of the assessment, refusing to answer or allow vital signs to be taken. The Risk Assessment showed her to be assaultive and homicidal.

Review of the Physician Orders by Staff I (MD) dated 11/30/2024, 11:04am, showed Patient #4 was placed on High-Risk Aggression/Homicidal Precautions.


Patient #5:

Observations of bedroom #206 on Unit 200 were conducted at 11:45am. Observations showed a placard to the right of the bedroom door with Patient #5 assigned to that room. Patient #5 was observed pulling a golf pencil out of his pocket, sitting on his bed, then replacing the pencil to his pocket.

Review of Psychiatric Evaluation by Staff K (MD) dictated 11/25/2024, 12:24pm, and signed 11/25/2024, 2:03pm, showed Patient #5 was a 26-year-old male with acute psychosis and aggression. He attacked his father. Police brought him to the hospital involuntarily.

Review of the Physician Orders by Staff L (DO) dated 11/25/2024, 1:02am, showed Patient #5 was placed on High-Risk Aggression/Homicidal Precautions.


Patient #6:

Observations of bedroom #207 on Unit 200 were conducted at 11:50am. Observations showed a placard to the right of the bedroom door with Patient #6 assigned to that room. Further observation of room 207 showed a golf pencil unattended on Patient #6's bedside table.

Review of Psychiatric Evaluation by Staff F (MD) dictated 11/22/2024, 3:12pm, and signed 11/23/2024, 6:32am, showed a 41-year-old male admitted under a mental health warrant. He was very paranoid, highly agitated, and aggressive requiring an injection of Haldol to calm down. He had a diagnosis of Schizophrenia, disorganized type.

Review of the Physician Orders by Staff F (MD) dated 11/22/2024, 6:00am, showed High-Risk Aggression/Homicidal Precautions.


In an interview with Staff M (Unit 200) on 12/3/2024, 12:04pm, she stated she was the charge nurse. She also stated patients on precautions "cannot have pencils in their room," adding, "Sometimes patients will put it [golf pencil] in their pockets and hide it." She ascertained through medical records review that Patient #5 and Patient #6 were on High-Risk Aggression/Homicidal Precautions. When informed that these two patients had golf pencils in their rooms, she was unable to verbalize the next step in securing the unit. Staff C spoke up, stating the unit needed to be "swept" for additional golf pencils. Both Staff M and Staff C stated the BIC pen should not be on the unit unattended. Staff M also stated she did not know how the pen got there.

In an interview with Staff A (Director of Quality) on 12/3/2024, 2:30pm, she stated a golf pencil should not be in a patient's room unattended. She stated she would explore options for a quick, efficient way to inventory golf pencils in the patient care areas. She also stated the BIC pen should not have been in a patient care area unattended.