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Based interview and record review, the facility failed to meet the Condition for Participation for the Governing Body when they failed to implement changes after an incident of a violation of a Patients Rights.

1. The Governing Body failed to discuss and implement changes to ensure 225 of 225 hospitalized patients received care in a safe setting following an incident of a violation of a Patients Rights. (Refer to A 063)

2. The facility failed to observe the patients' right to receive care in a safe setting for one of 30 sampled patients (Patient 1), when Patient 1 was placed in a closed room with Patient 2, who was on a 5150 hold (72 hour hold) for being a danger to self and others. Patient 2 had access to an unsecured oxygen cylinder tank and used it to beat Patient 1 over the head, face and chest. (Refer to A 115 and A 144)

3. Based on interview and record review, the facility failed to prevent physical abuse for one of 30 sampled patients (Patient 1), when Patient 2 assaulted Patient 1 with an unsecured oxygen cylinder tank. (Refer to A 115 and A 145)

4. Based on interview and record review, the facility's quality assurance program failed to develop a plan of action to ensure patients received care in a safe setting and be free from physical abuse for one of 30 sampled patients (Patient 1) after a Patient 2, who was deemed a danger to self (DTS) and a danger to others (DTO) was placed in the same room as an elderly patient (Patient 1) and assaulted him with an oxygen cylinder tank, that resulted in injury and death for Patient 1. (Refer to 283)

The cumulative effect of these systemic problems identified resulted in the failure to provide care in a safe setting and prevent physical abuse for one of 30 sampled patients (Patient 1) that resulted in Patient 1's death. The Governing Bodys' failure to implement changes to ensure patients received care in a safe setting and prevent physical abuse has the potential for all patients to be placed in an unsafe setting and in danger of physical abuse and death.

Based on interview and record review, the Governing Body failed to discuss and implement a plan of action to ensure 225 of 225 patients received care in a safe environment by continuing to allow the placement of psychiatric patients (patients suffering from mental health illness) with non-psychiatric patients, following an incident of a violation of a Patients Rights for one of 30 sampled patients (Patient 1). Patient 1 was placed in a closed room with Patient 2. Patient 2 deemed by the facility to be a danger to self and others. Patient 2 had access to an unsecured oxygen cylinder tank and beat Patient 1 over the head, face and chest. The incident resulted in Patient 1's death. (Refer to A 144 and 145)

This failure had the potential for all hospitalized patients to be placed in the same room as psychiatric (relating to mental illness) patients identified as a danger to self and others, and potentially beaten to death with medical equipment.

Findings:

On 1/6/2021 at 10:56 AM, during a concurrent interview and record review of the monthly governing body minutes from January to October 2020, the governing body representative (GBR) stated her role in the governing body was to document minutes for discussion in the once-a-month governing body meetings. The GBR runs all the board meetings. The GBR stated the governing body had not discussed Patient 1's death on 12/17/2021, that resulted after Patient 2 assaulted Patient 1 with an oxygen cylinder tank. The GBR stated the governing body had not implemented a plan of action to prevent the future placement of a patients and psychiatric (relating to mental illness) patients in the same room. The GBR provided the monthly governing body meeting minutes from January to October 2020 and did not provide meeting minutes for November and December 2020, and January 2021. The GBR verified no meeting minutes were provided for the last three months. In addition, GBR stated the last three governing body meetings addressed COVID - 19 (coronavirus disease 2019, a new virus that can spread from person to person, causing respiratory illness) related topics. The GBR verified there was no documented evidence indicating the governing body discussed Patient 1's death or the implemented a plan of action to prevent further incidents. In addition, the GBR verified that the combined meeting minutes titled, "Board of Directors and Medical Quality Assurance Board Committee Meeting," dated 12/28/2020, had no documented evidence to indicate Patient 1's death was discussed or that a plan of action had been implemented to prevent patients from being placed in the same room with potentially dangerous psychiatric (suffering from mental illness) patients.

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Patient Rights, as follows.

1. The facility failed to observe the patients' right to receive care in a safe setting for one of 30 sampled patients (Patient 1). The facility placed Patient 2 with Patient 1 in a room, with a closed door. Patient 2, a psychiatric (relating to mental illness) patient, was placed on a 5150 hold (72 hour hold) for threathening to kill his father and himself. The facility placed Patient 2 in an environment where he had access to objects that could be used to harm himself or others. Patient 2 beat Patient 1 over the head, face, and chest, with an unsecured oxygen tank.
(Refer to A 144)

2. Based on interview and record review, the facility failed to prevent physical abuse for one of 30 sampled patients (Patient 1), when Patient 2 assaulted Patient 1 with an unsecured oxygen cylinder tank. (Refer to A 145)

The cumulative effect of these systemic problems identified resulted in Patient 1's death and the potential for all 225 hospitalized patients to be placed in the same room with a psychiatric patient, creating an unsafe environment and the potential for physical abuse or death.

Based on observation, interview, and record review, the facility failed to observe the patients' right to receive care in a safe setting for one of 30 sampled patients (Patient 1). The facility placed Patient 2 with Patient 1 in a room, with a closed door. Patient 2, a psychiatric (relating to mental illness) patient, was placed on a 5150 hold (72 hour hold) for threatening to kill his father and himself. The facility placed Patient 2 in an environment where he had access to objects that could be used to harm himself or others. Patient 2 beat Patient 1 over the head, face, and chest, with an unsecured oxygen tank.

The deficient practice resulted in Patient 2 beating Patient 1 with an oxygen cylinder tank resulting in lacerations to Patient 1's head, face, and chest and had the potential for the potential placing of all 225 hospitalized patients with psychiatric patients in the same room, creating an safe environment. Patient 2 died the following day.

On January 4, 2021 at 7:08 PM, the survey team called an immediate jeopardy (IJ, identified non-compliance that makes serious injury, harm, impairment or death likely to occur to one or more recipients if the non-compliance is not corrected) situation in the presence of the chief nursing officer (CNO) and the senior director of clinical services (SDCS). 1. The facility failed to provide care in a safe setting for Patient 1 and had the potential to continue to cohort all 225 hospitalized patients with psychiatric patients. The CNO and the SDCS were informed of the immediate jeopardy situation regarding failure to provide care in a safe setting that resulted in Patient 1's death and the failure to make changes in the placement of psychiatric patients with non-psychiatric patients.

On January 6, 2021 at 3:10 PM, while surveyors were onsite, the immediate jeopardy situation was lifted after verifying an acceptable plan of action. 1. The plan of action indicated all 5150 holds regardless of diagnosis or isolation will be placed in a private or blocked room. Education material provided to staff starting on 1/4/2021 regarding the written changes in the placement of psychiatric (relating to mental illness) patients and sitter (a person who observes and monitors patients) requirements. Staff signature of training were collected. A permanent policy change was implemented regarding the placement of the placement of a patient under a 5150 hold (72 hour hold) regardless or diagnosis to be ratified on 1/8/2021.

Findings:

On 1/4/2021 at 2:06 PM, during the observation of the progressive care unit (PCU, a unit that continuously monitors patient's cardiac and respiratory status), observed the nurses' station with several video monitoring systems showing each patients' room on the floor. Doors to patient rooms remained closed. Registered nurses (RNs) carried cellular devices that displayed video monitoring of their patients.

On 1/4/2021, at 2:14 PM, during an interview, the director of progressive care unit (DPCU), a unit that continuously monitors patient's cardiac and respiratory status) stated the unit was designated for COVID - 19 (coronavirus disease 2019, a new virus that can spread from person to person, causing respiratory illness) patients. The DPCU stated she was notified on the early morning of 12/17/2020, that Patient 2 was being admitted in PCU into the same room as Patient 1. The DPCU stated both Patient 1 and 2 were on supplemental oxygen (oxygen therapy that provides extra oxygen to breathe in) from the wall outlet. There was a oxygen tank in the room designated for Patient 1 to deliver high flow oxygen (a device to deliver supplement oxygen through the nose. The DPCU stated Patient 2 should not have been placed in the room with patient 1 due to the hazards in the room including, cords, ligatures (a thing used for tying or binding something tightly) and the oxygen cylinder tank, because Patient 2 was deemed to be a danger to self and others upon admission. The DPCU stated she witnessed the aftermath of the incident on 12/17/2020 at 9:41 AM in the PCU. The DPCU stated she was called by the secretary (Sec 1) who informed her that Patient 2 hit Patient 1 with the unsecured oxygen cylinder tank. The DPCU stated she immediately went to Patient 1 and 2's room. Patient 2 was calm and sitting on the side of his bed. The nurse technician (nurse tech 1) was instructing Patient 2 to put the oxygen tank down. The entire bottom of the oxygen tank was bloody. The DPCU asked Patient 2 why he beat Patient 1. Patient 2 stated: "he pissed me off this morning". The DPCU stated the registered nurse (RN 1) was covering for the sitter (Sitter 1 [person who monitors and observes patients]). RN 1 noticed Patient 2 got out of bed and RN 1 began to gown up in personal protective equipment (PPE, gloves, gown). RN 1 opened the door and saw that Patient 2 had already struck Patient 1 on the left side of his head above his eye with an oxygen cylinder. The DPCU stated a code gray (a call for security personnel, indicating there is a dangerous person in the area) was called immediately. Security and other staff detained Patient 2. The respiratory therapist (RT 1) came to the room and immediately started suctioning the blood from Patient 1's mouth and the gashes (long deep slashes, cuts, or wounds) on the left side of his face. Due to the extent of the injuries, RT 1 was unable to suction through the mouth and had to suction Patient 1 through a gash in his face, that pushed one of Patient 1's front teeth through his face. Pain medication was administered to Patient 1. Patient 1's family members were notified. The chief nursing officer (CNO) was notified and called the sheriffs. Patient 2 was handcuffed and detained by the sheriffs in the same room until 7 PM, because it was a crime scene. Patient 2 was transferred to the mental health unit (MHU) at 7 PM.

On 1/4/2021 at 5:02 PM, during a second interview, the DPCU stated nurse tech 1 and RN 1 were not available for an interview because they were off on leave due to the trauma of witnessing the incident. The DPCU stated the facility had not implemented any changes on the placement of psychiatric (relating to mental illness) patients with non-psychiatric patients the incident on 12/17/2020. The DPCU stated the hospital has continued to place psychiatric patients in rooms with non-psychiatric patients. The DPCU stated no in-services or changes have been made at this time to prevent the placement of psychiatric patients in the same room with non-psychiatric patients.

A review of Patient 1's face sheet indicated Patient 1 was an elderly patient admitted to the facility on 12/8/2020 for shortness of breath.

A review of Patient 1's, "History and Physical", dated 12/8/2020 at 9:56 PM, indicated Patient 1's diagnoses included acute hypoxemic respiratory failure (severe low oxygen in the blood) secondary to COVID - 19 pneumonia (infection that inflames one or more air sacs in the lungs). Patient 1 was currently on a non-rebreather mask (a device used in medicine to assist the delivery of oxygen therapy for delivery of oxygen at high concentrations).

A review of Patient 1's, "Internal Medicine Progress Note", dated 12/16/2020 at 1:37 PM, indicated Patient "looks a little bit less agitated than yesterday but respiratory wise is about the same, still requiring high flow oxygen. Head shows no signs of trauma. Patient 1 looks tired and chronically sick. Able to follow commands."

A review of Patient 2's face sheet indicated Patient 2 was admitted to the facility on 12/15/2020 for a mental health evaluation.

A review of a document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment", dated 12/15/2020 at 4:30 PM, indicated Patient 2 had a history of schizophrenia (a serious mental health disorder in which people interpret reality abnormally). Patient 2 was taken the policy station by his parents because he threatened to kill his father and himself. Patient 2 deemed to be a danger to himself and a danger to others and was placed on a 72-hour hold for evaluation and treatment in the emergency department, just prior to Patient 2's admission.

A review of Patient 2's, "History and Physical", dated 12/16/2020 at 10:33 AM, indicated Patient 2 had a history of schizophrenia (a serious mental disorder in which people interpret reality abnormally), mental health disorder, and recent COVID - 19. Police were called on this patient as he was displaying aggressive behavior. On initial evaluation, patient was endorsing homicidal (murderous) and suicidal ideation (thoughts of intentionally causing ones' own death). He was placed on a 5150 hold and was initially going to be admitted to the mental health unit.

A review of Patient 2's, "Mental Health Consultation Note", dated 12/16/2020 at 6:43 PM, indicated Patient 2's diagnosis included COVID - 19 virus infection, schizophrenia (a serious mental disorder in which people interpret reality abnormally), agitation (sense of inner tension and restlessness), homicidal (murderous) behavior, suicidal risk, and psychosis (abnormal condition of the mind that results in difficulties determining with is real and not real).

On 1/4/2021 at 2:49 PM, during an interview, the registered nurse (RN 2) stated she witnessed the incident that took place on 12/17/2020. RN 2 stated she heard nurse tech 1 call for help. RN 2 stated she put on PPE and entered Patient 1 and 2's room. RN 1 stated she grabbed a sheet to compress the wounds and stop the bleeding on Patient 1's face. RN 2 stated blood was gushing from holes on the left side of his face. The left eyebrow was split open. The left eye split open so deep that whitish gray tissue protruded from the wound. The tooth on the left side of the mouth was protruding toward the palate (roof of the mouth). RN 2 stated began to suction Patient 1. RN 2 stated Patient 1's chest was protruding due to the blow to his chest by Patient 2 with an oxygen tank. The oxygen tank was immediately removed from the room. Patient 2 was removed from the room at 7 PM.

On 1/4/2021 at 3:10 PM, during an interview, the charge nurse of the mental health unit (CMHU) stated it would not be safe to place a patient with homicidal ideation's in the same room with a patient receiving comfort care (care focused on symptom control, pain relieve and quality of life).

On 1/4/2021 at 5:09 PM, during a second interview, RN 2 stated that normally all objects, cords, clothing, and oxygen tanks are removed from the rooms of patients on a 5150 hold because it's dangerous and a safety hazard. RN 2 also stated that since the incident, there has been no education or instruction provided to the staff to prevent the future placement of dangerous psychiatric patient in the same room with non-psychiatric patient and having access to medical equipment that can be used as a weapon.

On 1/4/2021 at 5:20 PM, during an interview, the chief nursing officer (CNO) stated psychiatric patients were placed with non-psychiatric patients all the time, and it was rare for an oxygen tank to be in the same room. The CNO stated usually psychiatric patients are placed in a ligature free room with a sitter to watch them. The CNO stated there was a sitter (Sitter 1 [a person who observes and monitors a patient) sitting outside of Patient 2's room. Sitter 1 observed Patient 2 via a cellular phone.

On 1/5/2020 at 8:03 AM, during a second interview, the CNO stated Patient 2 beat Patient 1 with an oxygen cylinder. The CNO stated it was not the best placement of Patient 2, in the same room as Patient 1. The door was shut. The CNO stated Patient 2 was extremely psychotic (a mental disorder characterized by a disconnection from reality). Patient 2 killed someone (Patient 1), and they could not deny it. Patient 1 passed the next day (12/18/2020). The CNO stated the incident was reported to the California Department of Public Health as a criminal act.

A review of Patient 1's, "Consultation Notes", dated 12/17/2020 at 2:42 PM, indicated Patient 1 was an elderly patient with a history of dementia (a group of conditions characterized by impairment of at least two brain functions, memory loss and judgement). Given his age and poor baseline functional status (low level ability to perform daily required activities), the family had him in as a do not intubate (DNI, chest compressions and cardiac drugs will be used, but no breathing tube will be placed) status. Patient 1 got into a conflict with his roommate (Patient 2), who had psychiatric (relating to mental health) co-morbidities (two or more diseases) and Patient 2 picked up Patient 1's oxygen tank and assaulted patient 1 by slamming the oxygen tank into his head. A trauma consult was emergently requested, upon arrival, Patient 1 had some epistaxis (nosebleed) coming from his left nose and his left face was noted to be sunken in the periorbital region (surrounding the eye). Patient 1 appeared to have some conjunctival hemorrhage (bleeding of the eye) and likely has a globe rupture (a condition where the integrity of the outer membranes of the eye are disrupted by blunt or penetrating trauma) on that side. Patient 1 is currently unresponsive and not talking. Patient 1 moving all extremities and localizing pain, but he opens eyes to painful stimulus only. Patient 1 is non-verbal. Patient 1 with an assault to the head sustaining terrible traumatic brain injury and facial fractures. The patient 1 was do-not-intubate status prior to the assault in the hospital. Security was called immediately. They restrained his neighbor (Patient 2) who has psychiatric co-morbidities for which he will be transferred to the psychiatric floor immediately. The family was called and family decided to make Patient 1 comfort measures only given his preexisting co-morbidities and decline in functional status. Patient will therefore be transitioned to comfort measures only.

A review of Patient 1's, "Critical Care Progress Note", dated 12/17/2020 at 10:35 AM, indicated Patient 1 with severe COVID - 19 pneumonia who is now a status post assault by another hospital patient (Patient 2). Patient 1 was having an argument with his roommate when the assailant (Patient 2) reportedly hit Patient 1 in the head repeatedly with an oxygen tank. Patient 1 was DNR/DNI (do not resuscitate/do not intubate). Physical exam indicated Patient 1 was obtunded (a depressed level of consciousness), appeared in acute distress secondary to pain. There was a 3.5 centimeter (cm) laceration (a deep cut or tear in the skin) to the right forehead, swelling around the left eye, flat left eyeball with obvious globe rupture (a condition where the integrity of the outer membranes of the eye are disrupted by blunt or penetrating trauma), epistaxis (nosebleed) is present to the left nostril, and poor dentition (condition of teeth). Lacerations noted to the neck. Patient 1 with altered mental status highly concerning for acute intracranial hemorrhage (bleeding inside the skull or brain), facial trauma with epistaxis and bleeding into the airway, open globe (a penetrating injury to the eye) and Covid - 19 pneumonia. The patient is not able to protect his airway with bleeding from facial trauma and altered mental status. Family decided to transition the patient to comfort care. Comfort focused treatment ordered.

A review of Patient 1's progress note, dated 12/17/2020 at 5:20 PM, indicated Patient 1 was assaulted by patient in bed 2 (Patient 2) this morning around 9:45 AM.

A review of Patient 1's, "Discharge Summary", dated 12/18/2020 at 11:50 AM, indicated Patient 1 was admitted with COVID pneumonia on high flow oxygen 100 percent (%) a few days ago. His roommate (Patient 2) who has psychiatric issues attacked Patient 1 with an oxygen tank matching his face. Patient 1 became comatose (in a deep state of unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness) and his family made him DNR (do not resuscitate) and placed him on comfort measures. Patient 1 expired today.

A review of Patient 2's, "nursing progress notes", dated on 12/17/2020 at 5:33 AM, indicated Patient 2 was admitted to the unit for COVID -19 and on a 5150 hold for suicidal ideation and being a danger/threatening to others.

A review of Patient 2's, "Assessments and Treatment", dated 12/17/2020 at 6:30 AM, indicated Patient 2 was agitated, anxious and uncooperative. Patient activity indicated Patient 2 was awake, agitated, went to the restroom did not want to go back in bed. Patient kept trying to go to Patient 1's bed. Security was called and patient was calmed a little and sat only. Behavior did change, more agitated.

A review of Patient 2's ,"Mental Health Consultation Note", dated 12/17/2020 at 10:38 AM, indicated patient 2 referred for evaluation for capacity currently on a 5150 hold (72 hour hold) and placed upon arrival at hospital emergency department due to threats to harm father. Patient referred for admission to the mental health inpatient unit that due to positive Covid - 19 test and ongoing acute clinical symptoms patient admitted to the Covid unit for further management with psychiatric oversight. Per report, patient earlier this morning reportedly assaulted his roommate apparently hitting him on the head with an oxygen tank.

A review of Patient 2's, "Assessment and Treatment", dated 12/17/2020 at 2:33 PM, indicated Patient 2 was aggressive, agitated, assaultive, homicidal, and impulsive. Patient 2 threatened to harm his father and assaulted his roommate with homicidal intent using an oxygen tank.

A review of Patient 2's, "nursing progress notes", dated 12/17/2020 at 2:38 PM, indicated the physician was called regarding Patient 2's current status. Physician ordered the patient to be admitted to the Mental Health Unit under the direct watch of sheriff deputies until the patient is interviewed by homicide detectives at that point he will be discharged to their custody.

A review of Patient 2's, "nursing progress notes", dated 12/17/2020 at 4:31 PM, indicated Patient 2 was admitted on a 72-hour hold for danger to self and danger to others from the medical floor after he attacked his roommate with an oxygen tank. Patient 2 arrived on the mental health unit accompanied by two sheriff deputies, two security officers and two mental health technicians transporting him in a gurney. Patient 2 stated he attacked his roommate because if you get attached first you die, but if you attack first they die.

A review of Patient 2's, "Mental Health Notes", dated 12/17/2020 at 5:32 PM, indicated Patient 2 was on a 5150 hold for being a danger to others (DTO) and referred to inpatient psychiatric unit for brief stabilization and processing by sheriffs department after physical assault of roommate while in the medical service, while undergoing treatment for COVID - 19.

A review of the the facility's policy and procedure titled, "Patients' Rights and Responsibilities", dated 9/14/2016, indicated all hospital employees, medical staff members and contracted agency staff performing patient care activities shall observe these patients' rights. Patients' rights and responsibilities included, the patient has the right to receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment.

A review of the facility's the facility's policy and procedure titled, "Patient Safety Plan", dated 1/4/2018, indicated the Hospital recognizes that patients, staff, and visitors have the right to a safe environment.

Based on interview and record review, the facility failed to prevent physical abuse for one of 30 sampled patients (Patient 1), when Patient 2, a dangerous psychiatric (relating to mental illness) assaulted Patient 1 with an unsecured oxygen cylinder tank. Patient 2 was on a 72 hour hold for threatening to kill his father and himself. The facility failed to implement changes to prevent the future placement of dangerous psychiatric patient with non-psychiatric patients.

This deficient practice resulted in Patient 1's death and had the potential to place all 225 hospitalized patients at risk of assault and death if they were placed in the same room with a dangerous psychiatric patient.

On January 4, 2021 at 7:08 PM, the survey team called an immediate jeopardy (IJ, denitrified non-compliance that makes serious injury, harm, impairment or death likely to occur to one or more recipients if the non-compliance is not corrected) situation in the presence of the situation in the presence of the chief nursing officer (CNO) and the senior director of clinical services(SDCS). 1. The facility failed to protect Patient 1 from physical abuse by Patient 2 and failed to implement a plan of action to prevent the future placement of dangerous psychiatric patients with non-psychiatric patients. The CNO and the SDCS were informed of the immediate jeopardy situation regarding the failure to prevent physical abuse that resulted in Patient 1's death and the failure to prevent the future placement of dangerous psychiatric patients with non-psychiatric patients.

On January 6, 2021 at 3:10 PM, while the surveyors were onsite, the immediate jeopardy situation was lifted after verifying an acceptable plan of action through staff interviews and the review of new policies. 1. A sitter (a person who observes and monitors patients) will be assigned in room or directly outside the room in view of the patient at all times. Education material provided to staff starting on 1/4/2021 regarding the written changes in the placement of psychiatric (relating to mental illness) patients and sitter requirements. Staff signature of training were collected. A permanent policy change was implemented regarding the placement of the placement of a patient under a 5150 hold (a code under the Welfare and Institutions Code, which allows an adult who is experiencing mental health crisis to be involuntarily detained for 72-hour psychiatric hospitalization when evaluated to be a danger to others or self, or gravely disabled) regardless or diagnosis to be ratified on 1/8/2021. All in-house psychiatric patients will be assigned to both a medical and a mental health registered nurse. Education also includes the sitter for the 5150 holds were be in full personal protective equipment (PPE) to prevent delays in sitter interventions.

Findings:

On 1/4/2021, at 2:14 PM, during an interview, the director of progressive care unit (DPCU), a unit that continuously monitors patient's cardiac and respiratory status) stated the unit was designated for COVID - 19 (coronavirus disease 2019, a new virus that can spread from person to person, causing respiratory illness) patients. The DPCU stated she was notified in the early hours on 12/17/2020, that Patient 2 was being admitted in PCU into the same room as Patient 1. The DPCU stated both Patient 1 and 2 were on supplemental oxygen (oxygen therapy that provides extra oxygen to breathe in) from the wall outlet. There was a oxygen tank in the room designated for Patient 1 to deliver high flow oxygen (a device to deliver supplement oxygen through the nose). The DPCU stated Patient 2 should not have been placed in the room with patient 1 due to the hazards in the room including, cords, ligatures (a thing used for tying or binding something tightly) and the oxygen cylinder tank, because Patient 2 was deemed to be a danger to self and others. The DPCU stated she witnessed the aftermath of the incident that took place on 12/17/2020 at 9:41 AM in the PCU. The DPCU stated the secretary (Sec 1) informed her that Patient 2 hit Patient 1 with the unsecured oxygen cylinder tank. The DPCU stated she immediately went to Patient 1 and 2's room. Patient 2 was calm and sitting on the side of his bed. The nurse technician (nurse tech 1) was instructing Patient 2 to put the oxygen tank down. The entire bottom of the oxygen tank was bloody. The DPCU asked Patient 2 why he beat Patient 1. Patient 2 stated: "he pissed me off this morning." The DPCU stated that the registered nurse (RN 1) was covering for Patient 2's sitter (person who monitors and observes the patient). RN 1 noticed Patient 2 got out of bed and RN 1 began to gown up in personal protective equipment (PPE, gloves, gown). RN 1 opened the door and saw that Patient 2 had already struck Patient 1 on the left side of his head above his eye with an oxygen cylinder. The DPCU stated a code gray (a call for security personnel, indicating there is a dangerous person in the area) was called immediately. Security and other staff detained Patient 2. The respiratory therapist (RT 1) came to the room and immediately started suctioning the blood from Patient 1's mouth and the gashes (long deep slashes, cuts, or wounds) on the left side of his face. Due to the extent of the injuries, RT 1 was unable to suction through the mouth and had to suction Patient 1 through a gash in his face, that pushed one of Patient 1's front teeth through his face. Pain medication was administered to Patient 1. Patient 1's family members were notified. The chief nursing officer (CNO) was notified and called the sheriffs. Patient 2 was handcuffed and detained by the sheriffs in the same room until 7 PM, because it was a crime scene. Patient 2 was transferred to the mental health unit (MHU) at 7 PM.

On 1/4/2021 at 5:02 PM, during a second interview, the DPCU stated nurse tech 1 and RN 1 were not available for an interview because they were off on leave due to the trauma of witnessing the incident. The DPCU stated the facility had not implemented any changes on the placement of psychiatric (relating to mental illness) patients with non-psychiatric patients the incident on 12/17/2020. The DPCU stated the hospital has continued to place psychiatric patients in rooms with non-psychiatric patients. The DPCU stated no in-services or changes have been made at this time to prevent the placement of psychiatric patients in the same room with non-psychiatric patients.

A review of Patient 1's medical record indicated Patient 1 was an elderly patient admitted to the facility on 12/8/2020 for shortness of breath.

A review of Patient 1's, "History and Physical", dated 12/8/2020 at 9:56 PM, indicated Patient 1's diagnoses included acute hypoxemic respiratory failure (severe low oxygen in the blood) secondary to COVID - 19 pneumonia (infection that inflames one or more air sacs in the lungs). Patient 1 was currently on a non-rebreather mask (a device used in medicine to assist the delivery of oxygen therapy and allowed for delivery of oxygen at high concentrations).

A review of Patient 1's, "Internal Medicine Progress Note", dated 12/16/2020 at 1:37 PM, indicated Patient 1 "looks a little bit less agitated than yesterday but respiratory wise is about the same, still requiring high flow oxygen. Head shows no signs of trauma. Patient 1 looks tired and chronically sick. Able to follow commands".

A review of Patient 2's medical record indicated Patient 2 was admitted to the facility on 12/15/2020 for a mental health evaluation.

A review of a document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment", dated 12/15/2020 at 4:30 PM, indicated Patient 2, had a history of schizophrenia (a serious mental health disorder in which people interpret reality abnormally) was taken the policy station by his parents because he threatened to kill his father and himself. Patient 2 was deemed to be a danger to himself and a danger to others and was placed on a 72-hour hold (when a person, as a result of a mental health disorder, is a danger to himself, herself or others, or gravely disabled and is placed against their will in psychiatric hospital for 72 hours) for evaluation and treatment.

A review of Patient 2's, "History and Physical", dated 12/16/2020 at 10:33 AM, indicated Patient 2 had a history of schizophrenia (a serious mental disorder in which people interpret reality abnormally), mental health disorder, and recent COVID - 19. Police were called on this patient as he was displaying aggressive behavior. On initial evaluation, patient was endorsing homicidal (murderous) and suicidal ideation (thoughts of intentionally causing ones' own death). He was placed on a 5150 hold (when a person, as a result of a mental health disorder, is a danger to himself, herself or others, or gravely disabled and is placed against their will in psychiatric hospital for 72 hours) for evaluation and treatment and was initially going to be admitted to the mental health unit. However, because patient 2 was COVID - 19 positive, tachycardic (elevated heart rate), tachypneic (elevated breathing), and had a worsening chest x-ray, psychiatry requested that patient be admitted to medicine service and they would consult on the patient.

A review of Patient 2's, "Mental Health Consultation Note", dated 12/16/2020 at 6:43 PM, indicated Patient 2's diagnosis included COVID - 19 virus infection, schizophrenia (a serious mental disorder in which people interpret reality abnormally), agitation (sense of inner tension and restlessness), homicidal (murderous) behavior, suicidal risk, and psychosis (abnormal condition of the mind that results in difficulties determining with is real and not real).

A review of Patient 2's, "nursing progress notes", dated on 12/17/2020 at 5:33 AM, indicated Patient 2 was admitted to the unit for COVID -19 and on a 5150 hold for suicidal ideation and being a danger/threatening to others. Patient 2 was calm and cooperative but refusing medications. Patient 2 currently denied suicidal ideation.

A review of Patient 2's, "Assessments and Treatment", dated 12/17/2020 at 6:30 AM, indicated Patient 2 was agitated, anxious and uncooperative. Patient 2 was observed for fall risk and suicide precautions. Patient 2's activity indicated Patient 2 was awake, agitated, went to the restroom did not want to go back in bed. Patient 2 kept trying to go to Patient 1's bed. Security was called and Patient 2 was calmed a little and sat only. Behavior did change, more agitated.

On 1/4/2021 at 2:49 PM, during an interview, the registered nurse (RN 2) stated she witnessed the aftermath of the incident that took place on 12/17/2020. RN 2 stated she heard nurse tech 1 call for help. RN 2 stated she donned PPE and entered Patient 1 and 2's room. RN 1 stated she grabbed a sheet to compress the wounds and stop the bleeding on Patient 1's face. RN 2 stated blood was gushing from holes on the left side of his face. The left eyebrow was split open. The left eye split open so deep that whitish gray tissue protruded from the wound. The tooth on the left side of the mouth was protruding toward the palate (roof of the mouth). RN 2 stated Patient 1 was gurgling and she began to suction him. RN 2 stated Patient 1's chest was protruding due to the blow to his chest by Patient 2 with an oxygen tank. The oxygen tank was immediately removed from the room. Patient 2 was removed from the room at 7 PM.

On 1/4/2021 at 3:10 PM, during an interview, the charge nurse from the mental health unit (CMHU) stated stated that prior to admitting a psychiatric (relating to mental illness) patient to the mental health unit (MHU), the patient must be medically cleared in a medical unit. The CMHU stated it would not be safe to cohort a patient with homicidal ideation's in the same room with a patient receiving comfort care.

On 1/4/2021 at 5:09 PM, during a second interview, RN 2 stated that normally all objects, cords, clothing, and oxygen tanks are removed from the rooms of patients on a 5150 hold because it's dangerous and a safety hazard. RN 2 also indicated that since the incident, there has been no education or instruction provided to the staff to prevent this from happening again.

On 1/4/2021 at 5:20 PM, during an interview, the chief nursing officer (CNO) stated psychiatric patients were placed in the same room with non-psychiatric patients all the time, it was rare for an oxygen tank to be in the same room. The CNO stated usually psychiatric patients are placed in a ligature free room with a sitter to watch them. The CNO stated a sitter (Sitter 1) was sitting outside of the room observing Patient 2 via a cellular phone.

On 1/5/2020 at 8:03 AM, during a second interview, the CNO stated the incident was investigated immediately. The CNO stated Patient 2 beat Patient 1 with an oxygen cylinder. The CNO stated it was not the best placement of Patient 2, in the same room as Patient 1. The door was shut because both patients were diagnosed with COVID -19. The registered nurse (RN 1) was covering for Sitter 1. The incident happened while RN 1 was putting on PPE (personal protective equipment, gloves, gown) prior to entering the room. The CNO stated Patient 2 was extremely psychotic (a mental disorder characterized by a disconnection from reality). Patient 2 killed someone (Patient 1), and they could not deny it. The CNO stated that family members were notified and requested for Patient 1 to remain as a DNO (Do Not Resuscitate), and implemented comfort care. Patient 1 passed the next day (12/18/2020). The CNO stated the incident was reported to the California Department of Public Health as a criminal act.

A review of Patient 1's, "Consultation Notes," dated 12/17/2020 at 2:42 PM, indicated Patient 1 was an elderly patient with a history of dementia (a group of conditions characterized by impairment of at least two brain functions, memory loss and judgement). Given his age and poor baseline functional status, the family had him in as a do not intubate (DNI, the placement of a breathing tube) status. Patient 1 got into a conflict with his roommate (Patient 2), who had psychiatric co-morbidities (two or more diseases) and Patient 2 picked up Patient 1's oxygen tank and assaulted Patient 1 by slamming the oxygen tank into his head. A trauma consult was emergently requested, upon arrival, Patient 1 had some epistaxis (nosebleed) coming from his left nose and his left face was noted to be sunken in the periorbital region (surrounding the eye). Patient 1 appeared to have some conjunctival hemorrhage (bleeding of the eye) and likely has a globe rupture (a condition where the integrity of the outer membranes of the eye are disrupted by blunt or penetrating trauma) on that side. Patient 1 was currently unresponsive and not talking. Patient 1 moving all extremities and localizing pain, but he opens eyes to painful stimulus only. Patient 1 was non-verbal. Patient 1 with an assault to the head sustaining terrible traumatic brain injury and facial fractures. The patient was do-not-intubate status prior to the assault in the hospital. Security was called immediately. They restrained his neighbor (Patient 2) who has psychiatric comorbidities for which he will be transferred to the psychiatric floor immediately. The family was called and family decided to make Patient 1 comfort measures only given his preexisting co-morbidities (two or more diseases) and decline in functional status. Patient 1 will therefore be transitioned to comfort measures only.

A review of Patient 1's, "Critical Care Progress Note", dated 12/17/2020 at 10:35 AM, indicated Patient 1 with severe COVID - 19 pneumonia who was now a status post assault by another hospital patient (Patient 2). Patient was having an argument with his roommate when the assailant (Patient 2) reportedly hit Patient 1 in the head repeatedly with an oxygen tank. Patient 1 was DNR/DNI (do not resuscitate/do not intubate). Physical exam indicated Patient 1 was obtunded (a depressed level of consciousness), appeared in acute distress secondary to pain. There was a 3.5 centimeter (cm) laceration (a deep cut or tear in the skin) to the right forehead, swelling around the left eye, flat left eyeball with obvious globe rupture (a condition where the integrity of the outer membranes of the eye are disrupted by blunt or penetrating trauma), epistaxis (nosebleed) is present to the left nostril, and poor dentition (condition of teeth). Lacerations noted to the neck. Patient 1 with altered mental status high concerning for acute intracranial hemorrhage (bleeding inside the skull or brain), facial trauma with epistaxis and bleeding into the airway, open globe (a penetrating injury to the eye) and Covid - 19 pneumonia. The patient is not able to protect his airway with bleeding from facial trauma and altered mental status. Family decided to transition the patient to comfort care. Comfort focused treatment ordered.

A review of Patient 1's progress note, dated 12/17/2020 at 5:20 PM, indicated Patient 1 was assaulted by patient in bed 2 (Patient 2) on 12/17/2020 at around 9:45 AM. Code gray was called. Security and multiple staff arrived at bedside. Sheriffs called by security. Patient 1's family member was informed via telephone.

A review of Patient 1's, "Discharge Summary," dated 12/18/2020 at 11:50 AM, indicated Patient 1 was admitted with COVID pneumonia on high flow oxygen 100 percent (up to 16 Liters/minute) a few days ago. His roommate (Patient 2) who has psychiatric issues attacked Patient 1 with an oxygen tank matching his face. Patient 1 became comatose (in a deep state of unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness) and his family made him DNR (do not resuscitate) and placed him on comfort measures. Patient 1 expired today (12/18/2020).

A review of Patient 2's ,"Mental Health Consultation Note," dated 12/17/2020 at 10:38 AM, indicated patient referred for evaluation for capacity currently on a 5150 hold (72 hour hold) for being a danger to others (DTO) placed upon arrival at hospital emergency department due to threats to harm father. Patient referred for admission to the mental health inpatient unit that due to positive Covid - 19 test and ongoing acute clinical symptoms patient admitted to the Covid unit for further management with psychiatric oversight. Per report, Patient 2 earlier this morning, on 12/17/2020, reportedly assaulted his roommate (Patient 1) apparently hitting him on the head with an oxygen tank. Patient 2 is likely facing legal charges but pending psychiatric stability due to past history for mental illness patient will be further monitored with attempt to stabilized with psychotropic (used to treat mental illness) medication pending release to law enforcement custody to discontinuation of 5150 hold.

A review of Patient 2's, "Assessment and Treatment", dated 12/17/2020 at 2:33 PM, indicated Patient 2 was aggressive, agitated, assaultive, homicidal, and impulsive. Patient 2 threatened to harm his father and assaulted his roommate with homicidal intent using an oxygen tank.

A review of Patient 2's, "nursing progress notes", dated 12/17/2020 at 4:31 PM, indicated Patient 2 was admitted on a 72-hour hold for danger to self and danger to others from the medical floor after he attacked his roommate with an oxygen tank. Patient 2 arrived on the mental health unit accompanied by two sheriff deputies, two security officers and two mental health technicians transporting him in a gurney. Patient 2 stated he attacked his roommate "because if you get attached first you die, but if you attack first they die". Patient 2 was pending interview by homicide detectives and discharge to the Sheriff's department for further treatment per their protocols, will continue to monitor and provide a safe therapeutic environment with level one precautions and one to one observation provided by two sheriff deputies.

A review of Patient 2's, "Mental Health Notes," dated 12/17/2020 at 5:32 PM, indicated Patient 2 was on a 5150 hold for being a danger to others (DTO) and referred to inpatient psychiatric unit for brief stabilization and processing by sheriffs department after physical assault of roommate while in the medical service, while undergoing treatment for COVID - 19. Patient 2 has been provided with a medical clearance from COVID - 19 by the medicine service and is transferred to inpatient psychiatric unit in separate area from regular patient care area for safety and further investigation by Sheriffs department as part of the booking process. Patient 2 re-evaluated earlier after initial evaluation and continues to admit to assaulting other patient but unclear as to motive.

A review of Patient 2's, "Provider Discharge Note," dated 12/17/2020 at 7:24 PM, indicated Patient 2 discharge plan. The plan was to discontinue the 5150 hold. Discharge to law enforcement custody. Medical/Psychiatric follow up as per corrections.

The facility's policy and procedure titled, "Patients' Rights and Responsibilities", dated revised date 9/14/2016, indicated all hospital employees, medical staff members and contracted agency staff performing patient care activities shall observe these patients' rights. Patients' rights and responsibilities included, patient has the right to receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment.

The facility's policy and procedure titled, "Assault/Abuse of a Non-dependent/Non-elder", dated 5/11/2020, indicated assault or abuse of a non-dependent/non-elder adults, by definition, will include the following conduct: including, murder, assault with a deadly weapon, firearm, assault weapon, or means likely to produce bodily harm.

Based on interview and record review, the facility's quality assurance program failed to discuss and implement a plan of action to ensure 225 of 225 patients received care in a safe environment by continuing to allow the placement of psychiatric patients (patients suffering from mental health illness) with non-psychiatric patients, following an incident of a violation of a Patients Rights for Patient 1. Patient 1 was placed in a closed room with Patient 2. Patient 2 identified as being a danger to self and others. Patient 2 had access to an unsecured oxygen cylinder tank and beat Patient 1 over the head, face and chest. The incident resulted in Patient 1's death. (Refer to A 144 and 145)

This failure had the potential for all hospitalized patients to be placed in the same room as psychiatric (relating to mental illness) patients identified as a danger to self and others, and potentially beaten to death with medical equipment.

Findings:

On 1/5/2021 at 8:31 AM, during an interview, the quality manager (QM) stated that the quality department and the leadership were immediately informed of the incident on 12/17/2020, when Patient 2 attacked Patient 1 with an oxygen cylinder tank, that resulted in injury and death for Patient 1. The QM stated the incident was investigated immediately. The QM stated Patient 2 was placed in the same room with Patient 1 because both patients were diagnosed with COVID -19 (coronavirus disease 2019, a new virus that can spread from person to person, causing respiratory illness) and the facility was trying to follow infection control guidelines. The QM stated Patient 2 had a sitter sitting outside of the room with the door closed, watching video of Patient 2 on the cellular phone to limit the sitters' exposure to COVID - 19. The QM was asked what had been done to prevent this type of incident from happening again. The QM stated the quality department discussed the possibility of having the sitter sit inside of the patient's room or have the sitter sit outside the patients' room with full personal protective equipment (PPE, gloves, gown, mask, face shield) for a quicker response if necessary. The QM stated that at this time there was no set plan to prevent the incident from reoccurring. Discussions were still in the works regarding infection control and the placement of a potentially dangerous patient in the same room with another patient. The QM stated no in-services had been provided to staff and no new changes in policies had been implemented to prevent this type of incident from happening again.

On 1/5/2021 at 11:45 AM, the senior director for clinical services (SDCS) stated the quality committee had not discussed Patient 1's death in the last meeting because they had not collected all the information surrounding the incident.

On 1/6/2021 at 10:46 AM, the facility's, "Board of Directors and Medical Quality Assurance Board Committee Meeting," minutes dated 12/28/2020, were reviewed with the QM. The QM verified the minutes did not address Patient 1's death that occurred on 12/17/2020, after Patient 2 assaulted Patient 1 an oxygen tank. In addition, the QM verified there was no documented evidence that a plan of action was developed or implemented to prevent this type of incident from happening again.

Based on observation, interview, and document review, the hospital failed to maintain a safe physical plant and environment, including oxygen cylinders, medical gas and vacuum system, and a fire smoke damper for a universe of 30 sampled patients.

This deficient practice had the potential for confusion and delay if a full oxygen cylinder was needed in a rapid manner, creating a mechanical hazard from a sudden uncontrollable release of the contents of high-pressure gas-filled cylinders, medical gas and air leaks, and creating a condition conducive to the spread of smoke and fire.

Findings:

During the Hospital Complaint Validation survey tour of the physical environment on 1/4/2021 from 12:01 p.m. to 3:30 p.m., the following conditions were observed:

Progressive Care Unit 2nd floor

1. Multiple oxygen cylinders (big tanks used as containers for life sustaining element of the air) were stored unlabeled as empty or full in the oxygen storage room. There were portable M-24 oxygen e cylinders (small/portable oxygen cylinders) stored in two racks next to each other. There was no signage on the wall, racks or anywhere else in the immediate area identifying which cylinders were empty. One of the two racks had a label at the back of the rack that was obstructed from view by the cylinders. Closer observation revealed the label identified the cylinders in that rack as full. The other rack had no label.

On 1/4/2021 at 3:05 p.m. during an interview, the Intensive Care Unit (ICU) Manager stated there was no empty cylinder signage.

NFPA 99 Health Care Facilities Code 2012 Edition section 11.6.5.3 indicates that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Intensive Care Unit (ICU) 2nd floor

2. An oxygen cylinder was not secured in room B-18. There was a portable M-24 oxygen e cylinder laying on its side on the floor near a patient bed.

On 1/4/2021 at 3:05 p.m. during an interview, registered nurse (RN 3) stated that she laid the cylinder on the floor because the patient was going to MRI and she did not want it in the way, but that the cylinder should have been placed in a cylinder stand.

Facility policy number CT 006, titled Transporting and Exchange of Oxygen E-Tanks, dated 12/17/19, indicated that each cylinder must be properly stored on a designated cradle or cart if being transported; No cylinder tank shall be stored on the floor or standing by itself.

NFPA 99 Health Care Facilities Code 2012 Edition section 11.6.2.3(11) indicates that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


During a tour of the hospital environment on 1/5/2021 from 8:30 a.m. to 3:00 p.m., the following conditions were observed:

3 North

An oxygen cylinder was stored unidentified as empty or full in the soiled equipment room. There was a portable M-24 oxygen e cylinder stored in a oxygen cylinder rolling cart. There was no signage on the wall, cart or anywhere else in the immediate area identifying if the cylinders was empty or full.

On 1/5/2021 at 2:05 p.m. during an interview, the Director of Engineering stated there was no signage indicating if the cylinder was empty or full, and that there needed to be signage indicating if the cylinder was empty or full.

NFPA 99 Health Care Facilities Code 2012 Edition section 11.6.5.3 indicates that empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

3 Tower

4. An oxygen cylinder was not secured in the Small Equipment Room. There was a portable M-24 oxygen e cylinder standing unsecured on the floor.

On 1/5/2021 at 2:20 p.m. during an interview, the Engineering Supervisor Plant Maintenance acknowledged the cylinder standing unsecured, stated the cylinder was full, and that it would be taken to be secured in a rack.

Facility policy number CT 006, titled Transporting and Exchange of Oxygen E-Tanks and dated 12/17/2019, indicated each cylinder must be properly stored on a designated cradle or cart if being transported; No cylinder tank shall be stored on the floor or standing by itself.

NFPA 99 Health Care Facilities Code 2012 Edition section 11.6.2.3(11) indicates freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

During the Hospital Complaint Validation survey document review on 1/6/2021, the following were discovered:

5. The Annual Medical Gas and Vacuum System Maintenance Inspection Report for testing conducted from 9/21/2020 to 9/24/2020 indicated on 9/23/2020, the Nitrous Oxide Cylinder Supply System had a change over regulator leaking at the bulk tank farm. There was no document evidence of corrective maintenance repair.

On 1/6/2021 at 1:00 p.m. during an interview, the Director of Engineering stated the regulator has not been corrected because the vendor is having problems getting the parts and was still waiting for the parts including the regulator.

6. The Annual Medical Gas and Vacuum System Maintenance Inspection Report for testing conducted from 9/21/2020 to 9/24/2020 indicated that on 9/23/2020, a medical gas outlet/inlet station was missing a release clip and had leakage at first floor Trauma room 3. There was no document evidence of corrective maintenance repair.

On 1/6/2021 at 1:00 p.m. during an interview, the Director of Engineering stated the outlet/inlet station has not been corrected because the vendor is having problems getting the parts and is still waiting for the parts.

7. The Six Year Fire Damper Inspection Report dated 6/22/2017 indicated four of 688 dampers failed. Continued review of the report revealed that three of the four dampers that failed had been corrected. One of the four dampers that failed had not been corrected. On 5/30/2017, fire smoke damper number 029 at the fifth floor lounge/conference room failed by having no power. There was no document evidence of corrective maintenance for damper 029.

On 1/6/2021 at 1:05 p.m. during an interview, the Director of Engineering stated he had not seen any documentation that damper 029 had been corrected, that it should have been corrected, and that he would follow up on it.