HospitalInspections.org

Based on review of facility policies and procedures, observations during tour, staff interviews and environmental safety round reports the facility failed to maintain seclusion rooms and patient toilet facilities to an acceptable level of safety.

Findings include:

Review of facility policy "Restrictive Interventions - Restraint and Seclusion" on 5/11/2011 dated 9/01/2010 revealed "Definitions: Seclusion: The involuntary confinement of a patient alone in a room or area for which the patient is physically prevented from leaving." Further review revealed "IV. Special considerations during restrictive interventions...D. Staff maintain the patient's safety, security...throughout the restrictive intervention."

Observation during tour of the U1 building 2 East patient care unit seclusion room on 5/10/2011 at 1450 revealed exposed edges of stiff, thin baseboard material that could be chipped off into approximately 3cm x 5cm pieces with sharp, jagged edges. Further observation of the patient toilet area during tour of the 2 East area revealed an empty metal toilet paper box which was loosely fitted to the wall and was easily bendable exposing sharp edges.

Interview with management staff during tour revealed "We will need to get those (baseboards) repaired." Further interview revealed the metal toilet paper roll box should either be tightly fitted to the wall or just removed if not being utilized to store the toilet paper. Interview revealed the items could be safety hazards because of the sharp edges.

Observation during tour of the U1 building 3West patient care unit seclusion room on 5/10/2011 at 1515 revealed exposed edges of hard, thin baseboard material that could be chipped off into pieces with sharp, jagged edges.

Interview with management staff during tour revealed "We will need to get those (baseboards) repaired." Interview revealed the items could be safety hazards because of the sharp edges.

Review of a facility environmental safety rounds report "Quarterly Inspection Findings" for 1st Quarter 2011 failed to reveal any findings of loose baseboards or loose toilet paper roll boxes for the U1 building identified.