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Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to protect a patient's right to be free from abuse & neglect (Patient # 1 ).

Facility staff failed to notify hospital nursing leadership and complete an Incident Report concerning an assault and an atttempted assault. This occurred on 2/21/2024 in the common day area of B-1/ B-2 Unit .

This deficient practice contibuted to an unsafe room assignment of Patient # 2 that led to the assault and subsequent death of Patient # 1.

Refer to Tag A-0145

Based on observation, interview, and record review, the facility failed to protect a patient's right to be free from abuse & neglect (Patient # 1 ).

Facility staff failed to notify hospital nursing leadership and complete an Incident Report concerning an assault and an attempted assault. This occurred on 2/21/2024 in the day area of Unit B-1/ B-2.

This deficient practice contributed to an unsafe room assignment of Patient # 2 that led to the assault and subsequent death of Patient # 1.

Findings included:

Review of facility self-reported incident, dated 2/22/2024, showed :

Patient # 1 was admitted on 2/21/2024 at 1:55 AM to B1/B2 unit with a diagnosis of major depressive disorder. He was assigned to room 211-A.

Patient # 2 was admitted on 2/20/2024 at 7 PM to A1/A2 unit with a diagnosis of schizophrenia. On 2/21/2024 around 8:30 AM, Patient # 2 got into a physical altercation and punched a peer on the left side of his face. An order was written to transfer Patient # 2 to B1/B2 unit. Patient # 2 arrived on the B1/B2 unit about 9 AM and was assigned to room 211-B.

Facility review of camera footage showed the first time Patients # 1 and # 2 were in room 211 together was on 2/21/2024 between 12:03 PM until 12:59 PM. The door was closed most all of this time period.

Patient # 2 came out of the room at 12:59 PM: video showed something red on his left hand. Patient # 2 approached another Patient (# 13) and hit him unexpectedly. A tech noticed a red substance on Patient # 2's hands that appeared to be blood; they didn't see blood on the other patient. Staff ran into the room (211) and found Patient #1 injured. A code was called; cardiopulmonary resuscitation (CPR) initiated; and an automatic external defibrillator (AED) was placed on Patent # 1 . No shock was indicated. Patient # 1 was transported via emergency medical services (EMS) to an acute care hospital. The facility was notified that Patient # 1 was pronounced dead at 2:04 PM.

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Record review of facility policy titled: "Patient Rights and Responsibilities, revised date 02/22/2023, showed: C. The Patient Bill of Rights shall include, but is not limited to, the patient's right to:....3. Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect...

Record review of facility policy titled : "Incident Report", revised 04/07/2020, showed:

-An Incident Report is to be completed for every occurrence which meets the following definition: any happening not consistent with the routine care or operation of the facility.
-The Incident Report must be completed immediately following an event that meets the above-mentioned definition.
-Categories to be reported include: assaultive behavior to peer; assaultive behavior to staff...;
-Notifications to (nursing) supervisor, as indicated.

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Facility staff interviews conducted on 3/01/2024 on unit B1 / B2 between 10:30 AM and 12:30 PM showed the following:

[*All staff interviewed verified they were present on the B1 / B2 unit the day Patient # 2 assaulted Patient ID # 1 in their shared room # 211]

A. Staff -H said :

-Patient # 2 was transferred from A1/A2 Unit because he tried to hit his room mate on that unit.

-This patient did not go directly into to his newly assigned room (211), but spent 30 to 40 minutes slowly walking around the the day room. While he was in the day room area, Patient # 2 attempted to assault another patient near the entrance to the group room. He also hit a Tech who tried to hold him back.

-Staff H verified this occurred prior to Patient # 2 entering his room (211) for the first time.

B. Staff -L said:

-Patient # 2 had been transferred to B1/B2 unit from a different unit because he hit another patient. He wandered around in the day room after he first got on our unit. Within less than an hour, he chased and tried to attack another patient ( identified him as Patient # 10 ).

-Staff L verified this occurred prior to Patient # 2 entering his room (211) for the first time.

C. Staff -F said:

-He was the charge nurse on the B1 / B2 unit the day Patient # 2 assaulted Patient ID # 1 in their shared room # 211. Staff F said he was unaware of Patient # 2's attempted assault of another patient and hitting a tech prior going into his room, # 211.

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Record review of facility House Supervisor reports for the night shift, dated 2/20/2024 and day shift, dated 2/21/2024, failed to show documentation that the house supervisor was notified of any attempted or actual assaults by Patient # 2 after he was transferred to B1/B2 Unit and before he entered his newly assigned room # 211.

Record review of all documented incident reports related to Patient # 2 : failed to show a documented variance report of the assault and attempted assault that occurred on 2/21/2024 shortly after this patient arrived in the B1/B2 unit.

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Video Footage Review: [video date & time reviewed: 2/21/2024 8:45 AM- 10 AM ]

Video camera footage review on 3/4/24 at 2:50 PM of B1/B2 Unit with Staff -A , Chief Executive Officer (CEO ) and Staff B, Chief Nursing Officer (CNO) CNO showed:

A common group room was visible on left side of view. This group room had glass walls which allowed visualization into room, partially seen on video; a common area dayroom in the middle encompassing the majority of the camera view; unit double door entrance/exit on right side of view.

At approximately 9:00 A.M., Patient # 2 was seen entering the unit through double doors escorted by two staff. He was wearing a black jacket and was barefoot. He then spent the next 40 minutes standing and pacing in the common area dayroom with the majority of time spent in the common area dayroom just outside the common group room. He was initially barefoot until he was offered socks by the staff at 9:15 A.M.. He temporarily sat down and allowed staff to place the socks on his feet. On three occasions after putting on the socks, the patient was seen requesting and receiving cups of water from staff at the nurse's station.

At 9:41 A.M. Patient# 2 was seen entering the common group room. Within 5 seconds he was seen running after another person, Patient # 10. Patient # 2 had both his fists held up in a fighting stance. Patient # 2 chased Patient # 10 outside the room and into the common day area. Several (at least three staff) were then seen intervening, surrounding Patient # 2 getting in between him and Patient # 10. Patient # 2 was then seen striking a mental health tech (MHT), Staff -K, with both arms simultaneously.

Patient # 2 subsequently appeared to have calmed down and was allowed to pace the unit again.

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During interviews conducted on 3/04/2024, immediately after video footage review , the CNO said "no one told us about this." Both the CEO and CNO acknowledged if they had known of the attempted / and actual assault, it would have changed the room assignment decision. Patient # 2 would not have been roomed with Patient # 1.

CNO later confirmed there were a total of 3 mental health techs (MHTs) seen in the video during the assaultive behavior event by Patient # 2 [ one (1) MHT stepped in between the patients; and 2 assisted during the event]. One (1) registered nurse (RN) assisted during the event. There was an additional RN and a licensed vocational nurse (LVN) viewed in the vicinity watching the event.