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Based on medical record review, review of shift report emails, review of grievances, review of the incident log, staff interview, and policy review, the facility failed to complete incident reports, failed to identify victims of patient to patient abuse, and failed to investigate incidents of physical abuse. (A0145)

Based on medical record review, review of shift report emails, review of grievances, review of the incident log, staff interview, and policy review, the facility failed to complete incident reports, failed to identify victims of patient to patient abuse, and failed to investigate incidents of physical abuse. This affected five (Patients #2, #3, #4, #6, and #11) of thirteen patients sampled for abuse and unidentified patients. The facility census was 96.

Findings include:

1. Review of shift report email, dated 10/01/2024 at 9:01 PM, revealed Patient #6 had an incident in the cafeteria in which she assaulted another patient with her food tray. Patient #6 denied the incident occurred and refused to move units.

Review of shift report email, dated 10/01/24 at 9:01 PM, revealed Patient #2 was assaulted by Patient #6 and made a police report. Patient #2 originally reported to the police she did not feel safe at the hospital and begged police to remove her from the facility. The officer explained to Patient #2 the staff would keep her safe and advised Patient #2 to move units. Patient #2 adamantly refused to move units.

Review of the medical record revealed Patient #6 was admitted to the hospital on 09/17/2024 with the diagnosis of severe manic bipolar disorder with psychotic features. Patient #6 was discharged home on 10/07/2024.

Review of nursing progress note dated 10/01/2024 revealed Patient #6 assaulted another patient in the cafeteria during dinner. The reason for the incident was unknown. Per witness statements, Patient #6 grabbed a meal tray and hit another patient several times. Right after the incident Patient #6 was brought back to the unit where she stated she smelled blood and did not recall the incident. The house supervisor was notified.

Review of nursing progress note dated 10/01/2024 at 9:40 PM revealed Patient #6 was informed she was on unit restrictions due to the incident in the cafeteria. Patient #6 stated staff were accusing her without the facts. Patient #6 had alternating periods of agitation and calm. Staff gave snacks, provided emotional support and offered Patient #6 to change units. Staff received orders for Level II medications as needed for agitation. Patient #6 threatened to fight staff if they attempted to administer injections.

Review of progress note dated 10/04/2024 revealed the local police interviewed Patient #6 regarding the incident in the cafeteria. Patient #6 did not recall the events on 10/01/2024. Police stated Resident #6 would not be charged.

Review of the medical record revealed Patient #2 was admitted to the hospital on 09/27/2024 with a diagnosis of major depressive disorder. Patient #2 was discharged to home on 10/03/2024.


Review of nursing assessment dated 10/01/2024 at 7:00 PM revealed Patient #2 interacted appropriately with staff and peers and denied acute distress. There was no assessment of injuries after the incident with Patient #6.

Review of nursing progress note dated 10/01/2024 at 10:00 PM revealed Patient #2 reported she continued to feel unsafe with a peer. Patient #2 was given the option to switch to another unit. Patient #2 stated she would switch units if her roommate could switch, too. Staff informed Patient #2 it was not possible and Patient #2 agreed to switch rooms. Staff assisted Patient #2 to gather belongings and reported the room change to the receiving nurse, provider, and house supervisor.

Review of the grievance log revealed Patient #2 filed a grievance report on 10/02/2024 at 10:33 AM. The patient advocate spoke with Patient #2 who stated she was in the cafeteria getting dinner when Patient #6 confronted her about cigarettes. During this confrontation Patient #6 began hitting Patient #2 with a food tray. Patient #2 used her arms to protect her face and head from injury and suffered bruises on her arms. Patient #2 returned to the unit and called the police. The police came and took Patient #2's statement.

Review of incident log revealed there was no incident report filed on 10/01/2024 regarding the incident between Patients #2 and #6 in the cafeteria.

During an interview on 11/25/2024 at 4:40 P.M. the Director of Quality (DQ) Staff A verified the incident which occurred on 10/01/2024 and between Patients #2 and #6 was not investigated. Staff A stated there was no documentation the patients involved in this incident were assessed or treated for injury.


2. Review of the medical record revealed Patient #4 was admitted to the hospital on 08/20/2024 for catatonia and psychosis. Patient #4 was discharged on 10/01/2024.

Review of Multidisciplinary Treatment Plan dated 08/20/2024 revealed Patient #4 had psychosis and mania related to diagnosis of bipolar I disorder with psychotic features. Interventions included group therapy, cognitive behavioral therapy, family therapy, activity therapy, Psychiatric medical provider to assess effectiveness of medications and adjust as needed, nursing to monitor/document all behaviors and provide patient educations as needed, and nursing to evaluate suicide risk twice daily.

Review of shift report email dated 09/26/2024 at 7:56 P.M. revealed Patient #4 was probated and required constant redirection. Patient #4 became aggressive and hit another patient on the head with a book. Patient #4 received level II intramuscular (IM) medications.

Review of shift report email dated 09/27/2024 at 8:27 PM revealed this shift Patient #4 hit two unidentified patients and smiled right after doing it.

Review of Nursing assessment dated 09/27/2024 at 11:00 P.M. revealed Patient #4 received IM Thorazine after two acts of physical aggression to two different peers.

Review of shift report email dated 09/28/2024 at 8:26 A.M. this shift Patient #4 hit two unidentified patients and smiled right after doing it. Thorazine was given orally and per IM injection.

Review of shift report email dated 09/29/2024 at 6:51 PM revealed Patient #4 was administered oral Thorazine due to increased agitation and attacking unidentified peers.

Review of nursing assessment dated 09/29/2024 at 7:00 PM revealed Patient #4 kept attacking unidentified white male peers on the unit and was given PRN medication for agitation.

Review of nursing assessment dated 09/30/2024 at 7:00 AM revealed Patient #4 was combative and aggressive towards unidentified patients and received PRN medications including oral Thorazine and IM Haldol and Ativan.

Review of shift report email dated 09/30/2024 at 7:31 PM revealed Patient #4 was given oral level II medications and was increased to one on one observation due to multiple assaults to other patients and staff.

Review of shift report email dated 09/30/2204 at 7:35 AM revealed on 09/29/2024 at 10:45 PM while going outside for a smoke break Patient #4 attacked Patient #10 by hitting her with a fist in the back without being provoked. The police came to the facility to take a statement from Patient #10 and staff asked police to return in the morning because it was late.

Review of incident report dated 09/30/204 at 12:00 AM revealed Patient #4 was walking and hit another patient who was seated in the back of the head. Both parties were assessed with no injuries noted. Patient #4 was sent to the quiet room.

Review of nursing assessment dated 10/01/2024 at 7:00 PM revealed Patient #4 was agitated, irritable and physically abused another patient. Patient #4 was taken to the quiet room and given an IM injection of Ativan, Haldol, and Benadryl.

Review of shift report email dated 10/01/2024 at 9:01 PM revealed Patient #4 was increased to one on one observation due to multiple assaults to other patients and staff. Patient #4 punched another patient in the face while receiving one on one observation.

Review of Patient #4's care plan revealed the care plan was reviewed by the multidisciplinary team on 09/30/2024. The care plan was never revised or updated after multiple acts of aggression resulting in physical contact with other patients.

Review of the medical record revealed Patient #3 was admitted to the hospital on 09/19/2024 with a diagnosis of severe bipolar disorder with psychotic features. Review of nursing assessment dated 10/02/2024 at 7:30 AM revealed Patient #3 received tramadol at 9:38 PM for complaint of pain in left cheek 6/10. Patient #3 was discharged on 10/02/2024. The record had no documentation regarding any incidents with other patients.

Review of shift report email dated 10/01/2024 at 9:01 PM revealed Patient #3 was punched in the face by another patient.

Review of the grievance log revealed on 10/02/2024 Patient #3 reported on 10/01/2024 he was sitting in the dayroom watching TV when Patient #4 punched him in the side of the face. Patient #3 stated he did not engage Patient #4 in any way. Patient #3 stated he was upset because the attack was unprovoked. Patient #3 stated he was assessed by nursing staff and his face was sore. He felt safe in the facility since Patient #4 had discharged.

Review of incident log revealed there was no incident report filled out for Patient #4's acts of physical assault against unidentified peers on 09/26/2024, 09/27/2024, 09/29/2024, and 10/01/2024, including the incident with Patient #3.

During an interview on 11/20/2204 at 3:34 P.M. Staff A stated there was no incident report or formal investigation of the event which occurred on 10/01/2024 between Patient #4 and Patient #3. Staff A stated staff should have filled out an incident report.

During an interview on 11/25/2024 at 4:40 P.M. Staff A verified there were no incident reports or investigations completed for Patient #4's assaults against other patients on 09/26/2024, 09/27/2024, 09/29/2024, and 10/01/2024. Staff A also the victims of Resident #4's physical attacks referred to in nursing assessments and shift report emails on 09/26/2024, 09/27/2024, and 09/29/2024 were never identified.

3. Review of the medical record revealed Patient #11 was admitted to the facility on 09/20/2024 with a primary diagnosis of major depressive disorder with psychotic features. Patient #11 was discharged to home on 09/28/2024.

Review of nursing assessment dated 09/27/2024 at 11:00 P.M. revealed Patient #11 got assaulted by a peer with no injuries. Every fifteen minute checks were continued for safety.

Review of the incident log revealed there was no incident report or investigation completed on 09/27/2024 involving Patient #11.

Review of the facility policy titled "Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation," dated 07/2024, revealed patients had the right to be free from real or perceived abuse from staff or other patients. All allegations, observations, or suspected cases of abuse that occurred in the facility will be investigated by the facility. Under the heading Procedures the policy states Reports must contain the following: Name, age and address of the patient; Nature and extent of the patient's condition; Basis of the reporter's knowledge; Any other relevant information. To protect the patient from any real or suspected physical abuse staff will safeguard patients from the offending individual.

Based on record review, shift report email review, review of the grievance log, staff interview, and policy review, the facility failed to ensure patients were assessed for injury after a choking incident for one patient (Patient #5) and after a patient-to-patient act of aggression resulting in physical contact for one patient (Patients #2) out of thirteen patients sampled. The facility census was 96.

Findings include:

1. Review of shift report email dated 09/26/2024 at 7:56 P.M. revealed there was a Code Blue call in the cafeteria when Patient #5 choked on beef stew.

Review of the medical record revealed Patient #5 was admitted to the facility on 09/20/2024 for severe recurrent Bipolar disorder with psychotic features. Patient #5 was discharged home on 09/30/2024.

Review of nursing assessment dated 0926/2024 at 7:00 P.M. revealed Patient #5 had no new or worsening problems. No assessment of the patient's respiratory status was documented following the choking incident.

During an telephone interview on 11/26/2024 at 9:42 A.M. Registered Nurse (RN) P verified he had cared for Patient #5 on 09/26/2024. RN P verified there was no nursing assessment completed because he had no recollection of a choking incident.

During an interview on 11/26/2024 at 10:17 A.M. RN House Supervisor O stated she recalled an unidentified patient care aide (PCA) had called a code blue during dinnertime on 09/26/2024 when Patient #5 choked on beef stew in the cafeteria. RN House Supervisor O stated upon arrival to the cafeteria she found several unidentified patients had jumped up to intervene and Patient #5 had cleared the big chunk of meat from her airway. RN House Supervisor O stated she did not assess Patient #5 for injury. The RN escorted Patient #5 back to the Meadows unit and reported the events to the nurse.

2. Review of shift report email, dated 10/01/24 at 9:01 PM, revealed Patient #2 was assaulted by Patient #6 and made a police report. Patient #2 originally reported to the police she did not feel safe at the hospital and begged police to remove her from the facility. The officer explained to Patient #2 the staff would keep her safe and advised Patient #2 to move units. Patient #2 adamantly refused to move units.

Review of the medical record revealed Patient #2 was admitted to the hospital on 09/27/2024 with a diagnosis of major depressive disorder. Patient #2 was discharged to home on 10/03/2024.


Review of nursing assessment dated 10/01/2024 at 7:00 PM revealed Patient #2 interacted appropriately with staff and peers and denied acute distress. There was no assessment of injuries after the incident with Patient #6.

Review of the grievance log revealed Patient #2 filed a grievance report on 10/02/2024 at 10:33 AM. The patient advocate spoke with Patient #2 who stated she was in the cafeteria getting dinner when Patient #6 confronted her about cigarettes. During this confrontation Patient #6 began hitting Patient #2 with a food tray. Patient #2 used her arms to protect her face and head from injury and suffered bruises on her arms.

Review of the undated document titled "Incident Investigation and Findings Checklist" revealed after every incident, patients involved were interviewed, assessments were completed in a timely manner, interventions were implemented as indicated, and treatment plans were updated.