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Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by having a seclusion room door with a missing screw in the door's deadbolt faceplate, causing the faceplate to move freely. The sharp edges of the faceplate were exposed, posing an injury risk to patients and staff. This deficient practice has the potential to affect 26 of 26 patients who are housed in the girls Dorm B and might be placed in the seclusion room.
Findings:

On 11/13/2023 at 3:35 p.m., observation of the door to the "Blue" seclusion room in Dorm B revealed the deadbolt's faceplate located on the door's edge was missing the lower screw and the faceplate was protruding outward and moving freely. The faceplate had sharp edges which were exposed, causing a potential risk for cutting injuries.

An interview at this time with S1Corporate Compliance confirmed that the loose faceplate had sharp edges and had the potential to cause injury to patients or staff who made contact with the plate.

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Based on observation, record review and interview, the hospital failed to analyze adverse patient events and implement preventive actions by failing to complete a thorough investigation of the cause of a patient's (Patient #1) laceration injury sustained while in Dorm B's seclusion room. The deficient practice has the potential to affect 26 of 26 patients residing in girls Dorm B.
Findings:

Review of an incident report dated 11/06/2023 at 5:45 p.m. revealed Patient #1 suffered a laceration injury to the ring finger of her right hand while in the seclusion room. The investigation conducted by the hospital staff concluded that she smashed her finger in the bottom of the door as it was closing. Due to the partially closed door obstructing the view, the injury was not witnessed by any of the staff and it was not visible on the video reviewed.
Patient #1 stated, "I went to get my shirt and my finger got cut in the door."

The investigation report revealed the door was initially inspected by the nurses and maintenance staff and they did not note any damage; they could not discern how the injury occurred.

Observation of the seclusion room door on 11/13/2023 at 3:30 p.m. revealed the dead bolt faceplate located on the door's edge was missing the lower screw and the faceplate was protruding outward beyond the door's edge. The faceplate had sharp edges which were exposed. In an interview at this time, S1Corporate Compliance confirmed they had not inspected the faceplate of the door during the inspection and were unaware of the missing screw. They had focused on the fact that the door was crooked and assumed she had injured her hand at the bottom of the door near the floor.

On 11/15/2023 at 8:45 a.m., an interview with Patient #1 confirmed she had cut her finger in the area of the door where the faceplate was protruding.