HospitalInspections.org
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LEMUEL SHATTUCK HOSPITAL
PATIENT RIGHTS
Tag No.: A0115
Based on interviews and a documents review, the hospital failed for one (Patient #1) of ten patients sampled to protect and promote the patient's rights.
See tag 0144.
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on interviews and a documents review, the hospital failed for one (Patient #1) of ten patients sampled to provide care in a safe setting.
Findings include:
The hospital report dated 09/24/2024, reported that on 09/11/2024 Patient #1 was using what was described as a "metal bit" object to attempt to self-harm Patient #1's right wrist. After the 1:1 staff observed Patient#1's self-harm to the right wrist, the 1:1 staff attempted to remove the "metal bit" object from Patient #1's possession, at which point Patient #1 swallowed the object. Diagnostic imaging was ordered and it was identified that two screws were in the stomach. As a result, Patient #1 was sent to an outside hospital for surgical evaluation and possible removal of the items.
The surveyor interviewed the Director of Quality and Risk (DQR) at 11:55 A.M. and again at 4:15 P.M. The DQR said that based on this event, the hospital implemented a corrective action plan that included:
1) Continuing the 1:1 constant observer on Patient #1
2) Conducting a review of Patient #1's privileges
3) Staff would conduct additional room sweeps (checking rooms for any potential harmful objects in Patient #1's environment) to include all rooms that Patient #1 enters on the unit, (prior to this event, room sweeps occurred only in Patient #1's living area).
The surveyor reviewed the hospital incidents report of Patient #1 on 03/12/2025. The surveyor reviewed a time period of six months from 09/12/2024 to 03/12/2025. The hospital incidents report of Patient #1 indicated that there were six self-harm events that occurred after the 09/11/2024 self-harm event. Three of the six self-harm events involved Patient #1 successfully retrieving items from Patient #1's environment.
Despite the hospital implementing an action plan after Patient #1's 09/11/2024 self-harm event, Patient #1 continues to find potentially dangerous items in Patient #1's environment, and continues to use those items for the purposes of self-harm.