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Based on record review, observation, and interview, the hospital failed to ensure the patient right to receive care in a safe setting by failing to ensure Unit A shared patient bathroom doors were closed and locked when unoccupied. This deficient practice presented a risk for patient harm or injury by patients being able to enter adjoining patient rooms through shared bathrooms and had the potential to impact all 13 Unit A patients on census at time of survey.
Findings:

Review of the hospital policy and procedure titled Patient Observation Rounds, reviewed and revised on 09/2024 revealed, in part:
Purpose: To ensure patient safety, as well as, to provide a process for observing and documenting patient location and behavior.
Procedure: 1.4 Ensure that doors are closed/latched/locked before letting go of the door handle/walking away.
MHT: Patient bathroom doors are closed and locked when unoccupied.

Review of a hospital Louisiana Department of Health Abuse and Neglect report revealed, in part, an alleged patient to patient sexual assault on Unit A that occurred on 09/12/2024 when patient #1 entered patient #3's room through a shared bathroom. Review of the report revealed a patient blocked the bathroom door from locking with toilet paper and paper towels which was not identified until after the allegation. Further review revealed staff should ensure patient bathroom doors were locked when unoccupied.

Review of Patient #4's medical record revealed patient assigned to room A. Further review revealed Patient #4 had orders for aggression and homicidal precautions.

Review of Patient #5's medical record revealed patient assigned to room B. Further review revealed Patient #5 had orders for suicide precautions.

Observation of hospital Unit A on 10/22/2024 at 2:16 p.m., with S1Director Risk Management, revealed Unit A had 12 double occupancy rooms and 12 shared bathrooms.

Observation of hospital Unit A on 10/22/2024 at 2:19 p.m. with S1Director Risk Management revealed patient room A and patient room B shared a bathroom. The bathroom was unoccupied at time of observation. Observation revealed room A patient bathroom door was open and not closed and locked. Further observation revealed patient room B was able to be accessed by walking through the shared bathroom.

In an interview on 10/22/2024 at 2:24 p.m., S1Director Risk Management confirmed the hospital policy was to ensure that patient bathroom doors were closed and locked when unoccupied. S1Director Risk Management confirmed that if a shared patient bathroom door was not closed and locked a patient from one room could enter the adjoining patient room.