HospitalInspections.org

Based on observations, staff interview and document review it was determined the facility failed to ensure care was provided in a safe setting in regards to three (3) handicap bathrooms on the A2, A3 and A4 nursing units. This failure has the potential for patients to harm themselves in a setting with hazards and during a time when there is no direct monitoring of the patients.

Findings include:

1. Unit A4 was observed at 1:40 p.m. on 12/7/15. It was observed that in the "back recreation area" there was a locked "handicap bathroom". The Nurse Manager of A3 who was present during the tour stated any patient may request to use that bathroom, and the room is unlocked and the patient is allowed to use the bathroom without any direct observation. It was observed the bathroom had hazards in the room including a tall looping faucet on the sink, open plumbing on the toilet, two (2) open handicap rails around the toilet, a round door knob on the inside side of the toilet room and a mechanical closing device on the top of the door on the inside of the toilet room. All of these items may be used by a patient to harm themselves by using them as a "looping device" in an attempt to harm themselves by hanging.

2. Unit A3 was observed at 2:25 p.m. on 12/7/15. The same Nurse Manager of A3 was present for the tour. An identical "handicap bathroom" was located in the same recreation area of the unit. The bathroom had the same potential hazards as the bathroom on unit A4.

3. Unit A2 was observed at 2:45 p.m. on 12/7/15. The same Nurse Manager of A3 was present for the tour. An identical "handicap bathroom" was located in the same recreation area of the unit. The bathroom had the same potential hazards as the bathrooms on units A4 and A3. The Nurse Manager of the A2 unit was present during part of the tour of the unit and she also concurred the patients may be allowed to use the bathroom without direct observation by staff.

4. The hospital policy, "Personal Hygiene and Grooming", last reviewed on 12/29/15, states in part: "Handicap restroom...When necessary or patient request, the handicap restroom can be utilized." There are no directives for staff to observe the patient's use of the restroom.