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RI HEALTH

Eleanor Slater Hospital workers face re-training after patient swallows razor

Despite patient pat downs and room searches being part of the hospital’s policy, there was no documentation to prove that the patient or their room had been properly checked

The Eleanor Slater Hospital in Cranston, RI.Lane Turner/Globe Staff

CRANSTON, R.I. — All health care workers at state-run Eleanor Slater Hospital will have to be re-educated on patient pat down and room searches after a patient was found face down with a hospital gown ties around their neck and admitted to swallowing a razor.

Over Columbus Day weekend in October, an unidentified patient with borderline personality disorder and history of self-harm was found on the bathroom floor of their unit with paper-like ties from a hospital gown tied around their neck and superficial cuts to their forearm. The patient was coherent and placed in a chair for assessment by the nursing staff.

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The patient then told a nurse that they had just swallowed the head of a shaving razor. They had been allowed to sign out the razorbefore entering the bathroom, according to a memo from the Rhode Island Department of Health.

The patient, who had just been admitted to Eleanor Slater in August 2021, after they could not be kept safe in a group home, which they had been admitted to by a court order. The patient, who was not identified by name or gender, was taken to Rhode Island Hospital, where the razor was removed.

Safety observation checks on the patient had changed from “every 5 minutes, to every 15 minutes” exactly two weeks before the incident, after the patient had spent a month at Eleanor Slater without harming themselves.

According to documents obtained by the Globe, a nurse told investigators that the patient had “earned the ability to use the razor” unsupervised, for hygiene purposes. But when the nurse was asked about the ties found around the patient’s neck, the nurse said the patient may have obtained the gown during an outside visit for a medical consult and hid it when she returned. The medical consult took place after an earlier incident of self-harm.

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Despite patient pat downs and room searches being part of the hospital’s policy, and a nurse telling investigators that they did occur, there was no documentation to prove that the patient had been searched.

On Wednesday, the hospital submitted a corrective action plan, which must be approved by the state health department. The plan outlined how it will re-educate all staff on searches when all patients enter and re-enter the Benton Building, which is a wing of the hospital that was recently upgraded to become a safer environment for psychiatric patients. The hospital’s leadership agreed that each search must be documented.

The plan also called for audits of patient searches and its corresponding documentation on a monthly basis, submitted to the hospital’s leadership team. The nurse manager will also have to ensure that the policy and procedures are reviewed and documented in the staff education files and reviewed during their performance reviews. “Progressive discipline” will be used in situations where there is “deliberate noncompliance,” according to the hospital’s corrective action plan.

The patient who was found on the bathroom floor will not be allowed to have a razor going forward, which will be permanently documented in their patient files.

The incident is one of many patient injuries that have raised questions at the state-run hospital. In August, a patient partially removed their own eye with a spoon. In September, a staffer was placed on leave for “tackling” a psychiatric patient to the ground, which caused them to have a medical episode.

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Alexa Gagosz can be reached at alexa.gagosz@globe.com. Follow her on Twitter @alexagagosz. Brian Amaral can be reached at brian.amaral@globe.com. Follow him on Twitter @bamaral44.