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RIVER PLACE BEHAVIORAL HEALTH
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on observation and interview the facility failed to ensure care in a safe setting. The deficient practice is evidenced by ligature risks present in the common areas of all the units.
Findings:
Tour of the facility on 11/02/2023 at 9:45 a.m. accompanied by S2DON revealed 2 phones on Unit "D" mounted on the wall in the common area with cords that were long enough to wrap around the neck. The cords were later measured to be 30 inches.
At the time of discovery, S2DON verified the cord was long enough to form a ligature. S2DON verified the patients are supposed to be chaperoned in the area, but out of precaution the ligature risk should be removed. S2DON verified there are 2 phones with similar length cords on all the units.
In interview on 11/02/2023 at 1:24 p.m., S1DR verified the phones are a part of the "Proactive Risk Assessment" and there was a recent incident reviewed where patients were unaccompanied in the room.