Resident Returns From Community Pass With Razor and Self-Inflicts Forearm Abrasion
Penalty
Summary
The facility failed to ensure a resident’s environment was free from hazardous materials when a resident with a history of mental illness and suicidal ideation obtained and used a razor to harm herself. The resident’s diagnoses included cannabis dependence, alcohol dependence, alcoholic cirrhosis, and depression, and a recent petition for involuntary/judicial admission documented that she was reasonably expected, unless treated on an inpatient basis, to engage in conduct placing herself or others at risk of physical harm, and that she had exhibited suicidal ideation with an attempt to cut or slit her wrist. On admission to the hospital, records described a wide linear abrasion on the left forearm beginning at the base of the left thumb and extending to the mid forearm on the radial side, approximately 1.5 inches in width, caused by a razor blade. A wound inspection form from the same date documented a small cut wound and abrasion on the left wrist. During the survey, a CNA reported that while performing night rounds she observed the resident in her room scraping her arm with a razor. When questioned, the resident stated she wanted to go to the hospital to be with her boyfriend and that she had brought the razor into the facility after being out on a community pass. The CNA noted a long scratch with bleeding on the resident’s forearm. The nurse supervisor confirmed that the resident reported obtaining the razor outside the facility and returning with it after a community pass, and he showed a picture of the razor, which had a straight blue handle with a brand label. The central supply staff member stated that the razors purchased for the facility had a curved handle and no brand label and confirmed that the razor used by the resident was not one of the facility’s razors. The administrator’s email correspondence to the psychiatrist and ombudsman documented that the resident had brought razors into the facility and harmed herself, confirming that the resident had access to a hazardous item despite her known risk for self-harm.
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