Based on observation, interview, and record review, the hospital failed to ensure the development, building and maintaining safe and/or seclusion rooms in the Emergency Department (ED). The ED is a triage unit for both the geographical region and the acute inpatient behavioral unit, for patients with behavioral and/or mental health issues, who are at risk for harming themselves or others. This deficient practice exposed all patients placed in these rooms with behavioral and/or mental health issues to potential physical harm in the ED. The findings are: A. On 04/13/15 at 9:05 am, during observation, the following was seen in the ED for both exam rooms #5 and #18, that were designated by the ED staff as safe and/or seclusion rooms: 1. Both rooms had a metal sink directly under an air conditioning vent (grill) with openings that were approximately 1 inch by 1 inch. (A patient could stand on the sink to access the vent grill.) 2. Two electrical sockets were on opposite walls, uncovered. (The sockets could be shorted.) 3. A single bed consisting of a metal frame wrapped with a wood frame was in the middle of the floor in each room. The wood could easily be broken creating potential tools or weapons. The beds in rooms #5 and #18 were unsecured and were easily moved. 4. A keypad for the electronic door lock was located just inside the door. It protruded just over an inch from the wall. A shoestring could be attached to the inside door handle and the keypad, thereby blocking access to the room from the outside. B. On 04/15/15 at 10:05 am, during observation, in the ED the following was observed in exam rooms #5 and #18: 1. The keypad just inside each door was gone. 2. The metal and wood frame beds were gone, both replaced by a transport cart. C. On 04/13/15 at 9:15 am, during interview, the ED physician #1(Staff #10) when asked how often does the ED triage serious Level I (potential harm to self and others) behavioral cases? He responded, "Almost daily." When asked if he thought the rooms being used as 'safe rooms' or 'seclusion rooms' "were appropriate?" He responded, "They 're what we have." When asked if he would prefer dedicated rooms that fulfill the criteria for both "safe" and/or "seclusion" he responded, "Sure." D. Record review of the facility's policy titled "Suicide Risk/Behavioral Disorder Assessment" dated 08/10 and revised on 08/11 and 09/11 the policy did not define "safe." The policy did not describe when it was appropriate for the needs of the patient, or how the direct staff would achieve it. Nor did the policy define a seclusion room, describe when it was appropriate for the needs of the patient, or how the direct staff would achieve it or direct how the staff would achieve it. E. Record review of the facility's quality reports indicated only "restraint episodes per 1000 patients broken down by unit." Use of ED exam rooms as "safe" or "seclusion" were not tracked by the ED or in the quality data. F. Record review of the ED list of patients reported by the facility that had been placed into rooms #5 and #18 from January 2015 through March 2015 for behavioral reasons revealed twenty-two different patients had been placed in these rooms due to behavioral reasons. G. Record review of the facilities Policy /Procedure titled "Restraint and Seclusion" dated 03/07 and revised on 02/15 indicated no definitions of a "safe" room or a "seclusion" room. Nor were there any specifications for such rooms contained in the document.