HospitalInspections.org

Based on interview and record review, the facility failed to ensure that one (#1) of nine patients in the Recreational Therapy Print Shop room was protected from injuries by ensuring that possible weapons were secured, monitored by staff, or removed from patient access, resulting in transfer to the hospital emergency department for treatment of head injuries including facial lacerations and multiple jaw fractures. Findings include:

On 5/2/19 at approximately 1130 an incident report for a patient to patient assault was reviewed with Staff B, Manager of the Psychosocial Rehabilitation Department, and the following was revealed:

An incident report completed by Staff Nurse H, dated 4/26/19 at 2230 noted that Patient #2 was the perpetrator of a Patient to Patient assault on Patient #1 on 4/26/19 at 1825. The report noted that the assault occurred in the Recreational Therapy Print Shop Recreational Therapy (PSR) room and documented that during the evening Print Shop session, Patient #2 hit Patient #1 with a golf club three times. The report noted that Patient #1 was taken to an acute care hospital for evaluation and treatment.

A Nursing Note for Patient #2 by Staff H dated 4/26/19 at 1825 noted the following, "tonight during evening PSR, the patient (#2) picked up a golf club (putter) that was in a bin and hit peer (#1) about three times before another peer (#3) was able to get this patient away from the other. The victim (#1) had been hit in the face and was bleeding heavily. Prior to this attack, the patient (#2) had court and just the day prior this patient (#2) saw the golf club in the bin and was pretending to putt with it. The patient (#2) was moved off this unit to another apartment and made a 1:1 (one to one) level of supervision."

A Psychiatrist's progress note dated 4/28/19 at 2304 for an assessment of Patient #2 on 4/26/19 (no time indicated) noted, "Patient assaulted his peer with a golf club causing significant injuries. "

On 5/2/19 at 1140, Staff H was interviewed regarding Patient #2's assault on Patient #1 on 4/26/19 with a golf club. Staff H reported that Patient #2 was one of nine patients who had PSR privileges. Staff H said that patients who had no "write ups" (undesirable behavior incidents) for three months and were assessed as mentally stable, with low risk of harm to themselves or others could apply to go to the PSR program. Staff H stated that Patient #2 did not have any behavioral incidents for six months before this incident happened. Staff H said that only patients who were stable and getting ready for discharge into the community were allowed in the PSR program.

Staff H stated that she was new as the manager of the Psychosocial Rehabilitation Department. Staff H said that on 4/24/19 she instructed her staff to clean out the storage areas in the PSR room and get rid of unnecessary items. Staff H stated that the PSR staff cleaned out a locked closed in the PSR room on 4/25/19 and placed unneeded things in a wheeled cart for the maintenance department to either throw away or store in the facility warehouse. Staff H said that Recreational Therapy Staff took three metal golf clubs (irons) out of the storage closet on 4/25/29 and put them in the wheeled cart and left the cart by the back wall of the PSR room. Staff H said that the Recreational Therapy Staff thought that Maintenance Staff were supposed to take the things in the cart away and store them in the warehouse, but Maintenance Staff thought that staff placed all items for storage or disposal in the building's enclosed loading dock. Staff H stated that there were two facility staff assigned to supervise patients in the PSR room at the time of the incident, Staff Nurse E and Recreational Therapist D. Staff H stated that the PSR patients were considered low risk for violence to self or others but the golf clubs should not have been left where the patients could get them.

On 5/3/19 at 1425 Staff Nurse E was interviewed by telephone regarding Patient #2's assault of Patient #1 with a golf club and said, "I was told that the Recreational Therapists cleaned out the closets and left three golf clubs (putting irons) in a wheeled cart at the back of the room. I was sitting at the desk in the front of the room. I saw (Patient #2) in the back right corner of the room where the cart was. I was told that the patients had been playing with the golf clubs the day before (4/25/19), pretending that they were playing golf. All of a sudden (Patient #2) grabbed the golf club and started swinging it at Patient #1's head. Patient #1 was sitting at the middle table with his head down, working on making a mother's day card. I didn't realize that the golf club was in there (in the cart). We didn't expect anything like that from (Patient #2). He's usually very quiet and keeps to himself. He might have been upset that day because he was in court that day. It happened so fast that (Patient #2) hit (Patient #1) with the golf clubs three times before I could get to him. The other patients jumped right in there and managed to get the golf club away from (Patient #2) and restrain him before I could get there. It all happened so fast."

On 5/3/19 at 1510, Recreational Therapist Staff D was interviewed and said that activity staff pulled three or four golf clubs out of the storage closed on Thursday (4/24/19) before the evening PSR session. Staff D said, "I put them (the golf clubs) in a big rolling tote that the warehouse sent over for me. They (warehouse) were supposed to come pick it up." Staff D was asked why the golf clubs were left in the PSR room where patients could access them for two days before Patient #2 used them to assault Patient #1. Staff D replied that Patients who were approved to attend print shop were supposed to be stable enough to use scissors and pencils.

On 5/2/19 at 1235 the Maintenance/Warehouse supervisor was interviewed and reported that Recreation Therapy staff were supposed to put any items for storage or disposal on the covered loading dock attached to the building. Warehouse staff pass by twice a day to pick up anything that's put out here."

A policy on hazardous/dangerous items/patient safety was requested but not provided.