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Based on document review and interview, the facility failed to ensure care in a safe setting in five (5) instances (see tag A144) and failed to ensure care in an environment free from physical and sexual abuse in one (1) instance (see tag A145).

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure that Patient Rights were provided in a safe manner.

Based on document review and interview, the facility failed to ensure care in a safe setting in five (5) instances. (Patient # 1, Patient # 3, Patient # 6, Patient # 7 & Patient # 12)

Findings include:

1. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated patients had the right to receive care in a safe setting. This policy was last revised in 09/2021.

2. Patient # 1's medical record (MR) indicated the following:
a. The patient was an 82 y/o (year/old) admitted on 02/17/2023, to rule out (r/o) of major depressive disorder and r/o major neurocognitive disorder, unknown etiology, with behavioral disturbances.
b. Daily Nursing Narrative dated 03/02/2023 at 9:15 PM, indicated the patient was slapped by patient # 2 in the face/nose. Patient # 1 had pain, redness and swelling to the bridge of nose.
c. The MR lacked documentation of communication to patient #1's power of attorney (POA), healthcare representative (HCR) and/or family that the facility communicated about incident with injury.

3. Patient # 2's MR indicated the following:
a. The MR for patient # 2 was reviewed and indicated the patient was an 81 y/o admitted on 02/11/2023, diagnosed with paranoid type delusional disorder and major neurocognitive disorder, unspecified type, severe.
b. Daily Nursing Assessment dated 03/02/2023, indicated patient # 2 slapped patient # 1 in the face, patient # 2's mood was defensive, guarded, and irritable, his/her behavior was impulsive and resistant, and he/she had been refusing medications.
c. The MR lacked documentation of initiation of adequate interventions related to (r/t) patient # 2's aggression to ensure other patients were not physically assaulted.

4. Patient # 3's MR indicated the following:
a. The MR for Patient # 3 was reviewed and indicated the patient was a 68 y/o admitted on 02/09/2023 with a diagnosis of schizophrenia, homicidal ideation, and depression.
b. Daily Nursing Narrative dated 03/02/2023, indicated the patient was yelling and was making threatening comments towards a Behavioral Health Associate (BHA). At that time, patient # 11 approached patient # 3 from the back and struck him/her on the side of the head knocking him/her into a chair. Redness to the right side of face, back of neck, and ringing of the ear noted by patient # 3 after incident.
c. Daily Nursing Narrative dated 03/02/2023 at 4:25 pm, indicated patient # 3 was sent to the ER for evaluation and treatment.
d. The MR lacked documentation of adequate initiation of 1:1 order with evidence it was carried out.

5. Patient # 6's MR indicated the following:
a. The MR for Patient # 6 was reviewed and indicated the patient was a 84 y/o admitted on 02/10/2023 with a diagnosis of schizoaffective disorder, dementia with behavioral disturbances and psychosis.
b. Daily Nursing Narrative dated 02/12/2023 at 5:00 pm, indicated the patient had been pushed down by patient # 9. Patient # 6's head was bleeding.
c. Obtained order to transport the patient to the ER.

6. Patient # 7's MR indicated the following:
a. The MR for Patient # 7 was reviewed and indicated the patient was a 58 y/o admitted on 02/12/2023 with a diagnosis of schizoaffective disorder, bipolar disorder, depression, and hemiplegia.
b. Daily Nursing Narrative dated 02/14/2023 at 7:00 pm, indicated patient # 7 was sitting at an activities table along with other patients. Another patient kicked patient # 8 under the table. At that time patient # 8 grabbed patient # 7's arm and bit down and then grabbed patient # 7's foot and bit the patient's toe.
c. Daily Nursing Narrative dated 02/19/2023 at 4:56 am, indicated the patient had been bitten on his/her right arm by patient # 8. The skin was broken, and teeth marks were visible. Patient requesting to be moved to another unit after being bitten twice.

7. Patient # 8's MR indicated the following:
a. The MR for Patient # 8 was reviewed and indicated the patient was a 20 y/o admitted on 01/31/2023 with a diagnosis of Autism, bipolar disorder, and aggression.
b. Medical Progress Note dated 02/14/2023 indicated the patient had bit another patient on the toe, on his/her arm and broke the skin. The patient was redirected and given an IM injection for his/her behavior. The MR lacked documentation of initiation of adequate interventions related to patient # 8's aggression to ensure other patients were not physically assaulted.
c. Psychiatric Progress Note dated 02/20/2023, indicated the patient presented anxious and agitated. Nursing reported that he/she had a hard time controlling his/her impulses. Patient # 8 bit another patient. Medication changes were made.
d. Psychiatric Progress Note dated 03/07/2023, indicated the patient bit another patient (patient # 12) on the forearm when he/she refused to give patient # 8 his/her coffee. The bite exposed veins, tendons, and muscle. The patient received an IM injection. At 5:00 am the patient walked up to a nurse and tried to bite him/her. Upon redirection, patient # 8 began to attack multiple different staff members, kicking, biting, and scratching. The patient was given medication and ordered to be in seclusion.
e. Medical Progress Note dated 03/07/2023, indicated the patient was placed on a 1:1 (one to one).
f. The MR lacked completed documentation on the Patient Observation Rounds during the time patient had been ordered to be a 1:1 observation by staff.

8. Patient # 9's MR indicated the following:
a. The MR for Patient # 9 was reviewed and indicated the patient was a 41 y/o admitted on 02/08/2023 with a diagnosis of schizoaffective disorder, depression, and intellectual disability.
b. Daily Nursing Narrative Note dated 02/12/2023 at 5:00 pm, indicated patient # 9 had to be redirected several times during the day. Nursing received IM injection orders for aggressive behaviors. Patient # 9 had been placed in isolation twice during the night. Patient # 9 pushed patient # 6 down in the milieu causing patient # 6 to strike his/her head. Patient # 9 was redirected to his/her room.
c. The MR lacked documentation of initiation of adequate interventions related to (r/t) patient # 9's aggression to ensure other patients were not physically assaulted.

9. Patient # 11's MR indicated the following:
a. The MR for Patient # 11 was reviewed and indicated the patient was a 30 y/o admitted on 03/01/2023 with a diagnosis of schizoaffective disorder, bipolar disorder, polysubstance abuse, and Tourette's syndrome.
b. Daily Nursing Assessment dated 03/02/2023, indicated the patient's mood was hostile, suspicious, and guarded. Patient # 11's behavior was impulsive and demonstrated threatening and/or aggressive behavior towards both staff and other patients.
c. Daily Nursing Narrative dated 03/02/2023 at 2:00 PM, indicated the patient had hit patient # 3 on the side of the head from behind, and it was hard enough to make patient # 3 fall into a chair.
d. Provider Order dated 03/02/2023 at 2:00 PM, indicated a transfer of patient # 11 to unit 300 from the 100 unit.
e. Physician Order dated 03/02/2023 at 2:40 PM, indicated the patient was placed on a 1:1 (one to one) observation due to (d/t) physical aggression and threatening behaviors toward others related to safety.
f. The MR lacked completed documentation on the Patient Observation Rounds during the time patient had been ordered to be a 1:1 observation by staff.

10. Patient # 12's MR indicated the following:
a. The MR for Patient # 12 was reviewed and indicated the patient was a 77 y/o admitted on 02/08/2023 with a diagnosis of anxiety, dementia, and depression.
b. Medical Progress Note dated 03/08/2023, indicated the patient had to be transferred out on the morning of 03/07/2023 due to another patient biting him/her. Patient # 12 was bleeding significantly and was sent out emergently. The patient was transferred from H # 1 (Acute Care Hospital) to H # 3 (Acute Care Hospital) due to artery damage.

11. Patient # 13's MR indicated the following:
a. The MR for Patient # 13 was reviewed and indicated the patient was a 24 y/o admitted on 02/28/2023 with a diagnosis of schizophrenia and intellectual disabilities.
b. Daily Nursing Narrative note dated 03/06/2023, indicated patients got into an argument and physically started fighting. Patients were redirected.
b. Psychiatric Progress Note dated 03/07/2023, indicated the patient had been attacked physically by another patient on the unit.

12. Patient # 14's MR indicated the following:
a. The MR for Patient # 14 was reviewed and indicated the patient was a 29 y/o admitted on 02/28/2023 with a diagnosis of bipolar disorder, anxiety, and suicidal ideation.
b. Provider Orders dated 03/01/2023, indicated the patient was to be placed on 1:1 supervision until DC (discontinued).
c. Provider Orders dated 03/06/2023, indicated the patient was ordered to be a 1:1 Observation due to threatening behaviors and homicidal ideation (HI).
d. Psychiatric Progress Note dated 03/07/2023, indicated the patient had a fist fight with another patient. Patient # 14 was the aggressor.
e. Provider Orders dated 03/08/2023, indicated to DC 1:1 Supervision and start Q5 (every 5 minutes) Supervision until discontinued.
f. The MR lacked appropriate documentation of 1:1 supervision.

11. In interview on 03/23/2023 at approximately 2:45 pm, with administrative staff A # 6 (Education/Interim Director of Nursing-DON), confirmed the facility was responsible for care in a safe setting, and no adequate interventions were put in place to ensure the above patients received care in a safe setting.

Based on document review and interview, the facility failed to ensure care in an environment free from physical and sexual abuse in one (1) instance. (Patient # 5).

Findings include:

1. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, indicated all patients have the right to be free of abuses or neglect as well as the fear of being abused or neglected. Sexual abuse is defined as a willful act which defies the sexual integrity of a patient through gestures, verbal and/or physical actions. This policy was last revised in 01/2020.

2. Patient # 5's MR (Medical Record) indicated the following
a. The patient was a 39 y/o admitted on 02/26/2023, with a diagnosis of bipolar disorder, anxiety, intellectual disability, and epilepsy.
b. Daily Nursing Narrative dated 03/03/2023, indicated this patient ran out of his/her room at 10:30 PM crying. Patient # 5 then notified staff that patient # 10 came into his/her room and stuck his/her tongue in patients # 5's mouth while he/she slept.
c. The MR Lacked documentation of notification of the incident to patient # 5's family, POA (Power of Attorney), and/or HCR (Healthcare Representative).

3. Patient # 10's MR indicated the following:
a. The patient was an 81 y/o admitted on 02/04/2023, with a diagnosis of dementia and homicidal ideation.
b. Daily Nursing Narrative dated 03/03/2023 timed 7:00 pm-7:00 am, indicated patient # 10 had been displaying inappropriate sexual advancements toward multiple patients. Patient # 10 tried to get close enough to kiss other patients by pretending to be asleep. When patient # 10 believed the staff was distracted, he/she would sneak into other patient's rooms. At 10:15 PM patient #5 ran out of his/her room crying, stated that patient # 10 had come into his/her room and stuck his/her tongue into the mouth of patient # 5's while asleep.
c. The MR lacked notification documentation of incident to patient #10's family, POA, and/or HCR. The MR also lacked initiating adequate interventions to ensure patients safety.

4. In interview on 03/23/2023 at approximately 2:45 pm with administrative staff member A # 6 (Education/Interim Director of Nursing-DON), confirmed the facility should initiate adequate interventions to ensure patient safety.

5. In interview on 03/23/2023 at approximately 2:50 pm with administrative staff member A # 6, confirmed the patient's family, POA and/or HCR should be notified when an incident occurs.

Based on document review and interview, the facility failed to ensure one (1) Registered Nurse (RN) was staffed on each unit in six (6) instances (see tag A392) and failed to ensure a registered nurse supervised and evaluated the care provided to 6 of 14 patients (see tag A395).

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure that Nursing Services were provided in a safe manner.

Based on document review and interview, the facility failed to ensure one (1) Registered Nurse (RN) was staffed on each unit in six (6) instances. (100, 200 & 300 units)

Findings include:

1. The facility policy titled, "Staffing Plan", PolicyStat ID 13219046, indicated under no circumstances shall there be less than one (1) RN on each unit, if the unit had more than one (1) patient. This policy was last revised in 02/2023.

2. Review of the staffing schedule for the 100 unit indicated the following:
a. On 02/16/2023 the patient census was 23 and there was not an RN scheduled on either the day or night shift.
b. On 02/28/2023 the patient census was 26 and there was not an RN scheduled on the day shift.
c. On 03/02/2023 the patient census was 26 and there was not an RN scheduled on the day shift.
d. On 03/04/2023 the patient census was 25 and there was not an RN scheduled on the day shift.

3. Review of the staffing schedule for the 200 unit indicated on 03/05/2023 the day shift lacked an RN.

4. Review of the staffing schedule for the 300 unit indicated on 02/18/2023 the day and night shift lacked an RN.

5. In interview on 03/23/2023 at approximately 2:30 pm with A # 6 (Education/Interim Director of Nursing), confirmed according to policy each unit should be staffed with an RN.

Based on document review and interview, the registered nurse failed to ensure a patient's skin assessment was documented after an injury in two (2) instances (Patient # 6 & Patient # 7), failed to ensure a patient's family, healthcare representative (HCR) and/or power of attorney (POA) were notified regarding being transported to the ER (Emergency Room) in three (3) instances (Patient # 3, Patient # 4 & Patient # 6), failed to ensure the family, HCR and/or POA was notified regarding a patient being transferred to jail in one (1) instance, failed to ensure 1:1 (one to one) observation patients had appropriate documentation, and failed to document patient belongings on the intake form in two (2) instances.

Findings include:

1. The hospital policy titled, "Skin Assessment", PolicyStat ID 12385990, indicated the guidelines are to identify and document any area of concern related to patient skin. This policy was last revised in 09/2022.

2. The hospital policy titled, "Transfer of Patient", PolicyStat ID 10623375, indicated Social Services and/or Nursing would communicate with the family and/or representative the reason, date and time of the transport. This policy was last revised in 10/2021.

3. The hospital policy titled, "Management of Patient Belongings", PolicyStat ID 12508268, indicated upon admission, staff would inventory all patient belongings, and sign the Personal Belongings Inventory form. This Policy was last revised in 05/2021.

4. The hospital policy titled, "Patient Observation", PolicyStat ID 12931622, indicated patients would continue to be assessed and monitored during their treatment to ensure observation levels were appropriate. Level III (3) - 1:1 Observation - the patient should be under cosntant visual observation by an assigned staff member, regardless of other unit activities. Documentation of all observations would be completed in the patient's record. The staff complete the patient observation record using a coding system described on the Patient Observation Monitoring Form. The staff will initial, date and/or time appropriate documentation in the designed areas for observation of a patient. This policy was last revised in 01/2023.

5. The medical record (MR) for Patient # 3 was reviewed and indicated the patient was a 68 y/o (year/old) admitted on 02/09/2023 with a diagnosis of schizophrenia, homicidal ideation, and depression. Daily Nursing Narrative dated 03/02/2023, indicated the patient was yelling and was making threatening comments towards a Behavioral Health Associate (BHA). At that time, patient # 11 approached patient # 3 from the back and struck him/her on the side of the head knocking him/her into a chair. Redness to the right side of face, back of neck, and ringing of the ear noted by patient # 3 after incident. Daily Nursing Narrative dated 03/02/2023 at 4:25 pm, indicated patient # 3 was sent to the ER for evaluation and treatment. The MR lacked documentation that family, HCR and/or POA was notified of the incident involving injury and/or transport.

6. The medical record (MR) for Patient # 4 was reviewed and indicated the patient was a 72 y/o admitted on 02/10/2023 with a diagnosis of major depressive disorder, severe, with psychosis. Daily Nursing Narrative dated 02/28/2023 at 12:15 am, indicated the patient fell and hit his/her head while running away from the nursing staff who were attempting to administer an IM (intramuscular) injection. Post-Fall Huddle Form dated 2/28/2023 at 12:15 am, indicated the provider, manager, director of nursing and the chief executive officer were notified. An order was obtained to transport the patient to the ER for evaluation/treat. Daily nursing Narrative dated 2/28/2023 at 1:50 am, indicated the patient was transported to the ER. The MR lacked documentation of the completed Personal Belongings Inventory Form and lacked that the family, HCR and/or POA had been notified of the incident involving an injury (fall) and/or of the transport.

7. The MR for Patient # 6 was reviewed and indicated the patient was a 84 y/o admitted on 02/10/2023 with a diagnosis of schizoaffective disorder, dementia with behavioral disturbances and psychosis. Weekly Skin Assessment dated 02/10/2023 (admission) showed bruising to the patient's forehead, left posterior wrist, right posterior hand, and right foot base of toes. Daily Nursing Narrative dated 02/12/2023 at 5:00 pm, indicated the patient had been pushed down by patient # 9. Patient # 6's head was bleeding. Obtained order to transport the patient to the ER. The MR lacked the 02/12/2023 skin assessment entry (head injury) and the 02/12/2023 documentation the family, HCR and/or POA was notified regarding the incident involving injury and/or transport.

8. The MR for Patient # 7 was reviewed and indicated the patient was a 58 y/o admitted on 02/12/2023 with a diagnosis of schizoaffective disorder, bipolar disorder, depression and hemiplegia. Daily Nursing Narrative dated 02/14/2023 at 7:00 pm, indicated patient # 7 was sitting at an activities table along with other patients. Another patient kicked patient # 8 under the table. At that time patient # 8 grabbed patient # 7's arm and bit down and then grabbed patient # 7's foot and bit the patient's toe. The MR lacked skin assessment documentation post patient injuries.

9. The MR for Patient # 8 was reviewed and indicated the patient was a 20 y/o admitted on 01/31/2023 with a diagnosis of Autism, bipolar disorder, and aggression. Medical Progress Note dated 02/14/2023 indicated the patient had bit another patient on the toe, his/her arm and broke the skin. The patient was redirected and given an IM injection for his/her behavior. At that time the MR lacked documentation of initiation of timely adequate interventions.
Psychiatric Progress Note dated 02/20/2023, indicated the patient presented anxious and agitated. Nursing reported that he/she had a hard time controlling his/her impulses. Patient # 8 bit another patient. Medication changes were made. The MR lacked documentation of initiation of adequate interventions related to patient # 8's aggression to ensure other patients were safe. Psychiatric Progress Note dated 03/07/2023, indicated the patient bit another patient (patient # 12) on the forearm when he/she refused to give patient # 8 his/her coffee. The bite exposed veins, tendons, and muscle. The patient received an IM injection. At 5:00 am the patient walked up to a nurse and tried to bite him/her. Upon redirection, patient # 8 began to attack multiple different staff members, kicking, biting, and scratching. The patient was given medication and ordered to be in seclusion. Medical Progress Note dated 03/07/2023, indicated the patient was placed on a 1:1 (one to one). The MR lacked completed documentation on the Patient Observation Rounds during the time patient had been ordered to be a 1:1 observation by staff.

10. The MR for Patient # 11 was reviewed and indicated the patient was a 30 y/o admitted on 03/01/2023 with a diagnosis of schizoaffective disorder, bipolar disorder, polysubstance abuse, and Tourette's syndrome. Daily Nursing Assessment dated 03/02/2023, indicated the patient's mood was hostile, suspicious, and guarded. His/her behavior was impulsive and demonstrated threatening and/or aggressive behavior towards both staff and other patients. Daily Nursing Narrative dated 03/02/2023 at 2:00 PM, indicated the patient had hit patient # 3 on the side of the head from behind and it was hard enough to make patient # 3 fall into a chair. Provider Order dated 03/02/2023 at 2:00 PM, indicated to transfer patient # 11 to unit 300 from the 100 unit. Physician Order dated 03/02/2023 at 2:40 PM, indicated to place patient on a 1:1 (one to one) observation due to (d/t) physical aggression and threatening others/safety. Daily Nursing Narrative dated 03/02/2023 at 3:30 PM, indicated patient # 11 was taken into custody by PD # 1 (Police Department) and removed from the hospital. The MR lacked documentation that the family, HCR, and/or POA had been notified of the incident and/or transfer to PD # 1. The MR also lacked Patient Observation Rounds completed documentation during the time patient had been ordered a staff 1:1 observation.

11. In interview on 03/23/2023 at approximately 11:30 am with administrative staff member A # 8 (Vice President of Quality & Compliance), confirmed there should be documentation on the Weekly Skin Assessment form for when there was a change in condition (injury) related to the patient's skin.

12. In interview on 03/23/2023 at approximately 2:50 pm with administrative staff member A # 6 (Education/Interim Director of Nursing-DON), confirmed the Patient Observation Rounds form should be filled out completely when patients are on a staff 1:1 observation, the family should be notified after an injury and whenever the patient needs to be transported to the ER for evaluation/treatment. He/she further confirmed the patient's belongings, whatever they arrive to the facility with, should be documented on the Patient Belongings Inventory form upon admission.




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