HospitalInspections.org

Based on observation, record reviews, and interviews, the hospital failed to ensure one of three patients (Patient # 1) received care in a safe setting in that:

The hospital failed to remove a sharp object (pencil) potentially usable in self-harm in the patient's room.
This failure placed the patient(s) at increased risk of harm to self and others.

Findings included:

Patient #1 Hospital intake Assessment dated 12/10/18 revealed he was a 21-year-old male admitted to hospital due to psychosis and homicidal ideation. He had threatened to set a church on fire and kill self after being caught. Disposition was checked "inpatient level of care due to behavior that is imminently threatening, destructive or dangerous to self or others."

During observational rounds on the hospital's 4Th floor adult male unit on 12/11/18 at 10:45 AM, revealed a sharpened pencil in Patient # 1 room shelve.

Interview with hospital Personnel # 1 on 12/11/18 at 11:15 AM confirmed the presence of the sharp object (Sharpened pencil) in patient's room. Personnel #1 stated "I don't know how he got the pencil. He is not supposed to have it." Personnel # 1 reported Patient # 1 was on suicidal precaution."

Interview with hospital Personnel # 2 on 12/11/18 at 11:30 AM revealed Patient #1 was not supposed to have a pencil in the room, since was on suicidal precaution. Personnel #2 reported environmental checks were carried out every shift and patients were on 15 minutes monitoring. Personnel #2 reported she was not aware Patient #1 had a sharpened pencil in the room.

Record review on 12/11/18 at 12:30 PM on Patient #1's High Risk Notification Alert completed during intake assessment dated 12/11/18 at 0041, revealed Patient #1 was suicidal/self-harm and homicidal (Plan to burn down church).

Interview with hospital Personnel # 3 on 12/11/18 at 12:45 PM revealed patients on suicidal watch were not supposed to possess pencils in their room. Personnel # 3 reported staff members were trained during orientation and on annual competency skill training on suicide and self-harm prevention.

Review of hospital policy titled "Suicide and Self Harm Prevention" with a review date 09/2016 reflected "initiate reasonable precautionary measures and provide special care for patients who are assessed as high risk for suicide behavior and/or self-injury behavior .... patients may not have access to pencils."