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Based on interviews with administrative staff, review of facility documents, and review of medical records, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

42 CFR 482.13: Patient Rights (Cross Reference Tag A-0115 and Tag A-0144).

42 CFR 482.21: QAPI (Cross Reference Tag A-0263 and Tag A-0273).

Based on staff interviews, review of two (2) out of two (2) Medical Records (#4 and #6), review of facility policies and procedures, and review of related facility documentation, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

The facility failed to ensure that patients had the right to receive care in a safe setting. (Refer to Tag A-0144)

Based on staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure a safe care setting for all patients on the Holly Hall A unit by failing to address and implement effective interventions for a patient (Patient #6) with a long history of aggression and assault behaviors on the unit. In addition, between November 2021 and 4/12/22, the Holly Hall A Forensic Unit has had 45 incidents of patient assaults with 22 of the assaults resulting in harm.

Findings include:

1. On 4/7/22 at 11:23 AM, Medical Record #4 was reviewed and revealed that on 4/2/22 at 1:50 PM, Patient #4 (victim) was assaulted, by Patient #6 (aggressor) resulting in Patient #4 having multiple facial fractures (right maxillary sinus, right orbit and bilateral nasal bone). Patient #4 was transferred to the hospital for treatment and Patient #6 was counseled.

2. On 4/7/22 at 1:45 PM, in the Holly Hall Forensic Building, interviews with Staff #19, #20, #21 and #22, and interview with Patient #4 revealed that on 4/2/22 at 1:50 PM, while asleep in his/her room, Patient #4 (victim) was assaulted by Patient #6 (aggressor), unprovoked.

a. On 4/7/22 at 2:04 PM, during an interview, Staff #21 indicated that after the assault, Patient #6 went back to his/her room. While staff were caring for Patient #4, Patient #6 re-entered Patient #4's room, and assaulted Patient #4 a second time.

b. At 2:36 PM, during an interview, Staff #22 stated that while he/she and two others were caring for Patient #4, who was bleeding, Patient #6 re-entered Patient #4's room, pushed three staff aside and continued to assault Patient #4 by punching him/her in the head. Staff #22 indicated that he/she tried to pull Patient #6 away from Patient #4 but stated Patient #6 was too strong. At that point, a Psychiatric Code (an overhead page that is called by any staff who determine that the patient is not in control after de-escalation is attempted) was called and one (1) additional staff member arrived.

c. At 2:49 PM, during an interview, Patient #4 stated that while he/she was asleep in his/her room, Patient #6 entered and "punched me in my face and fractured my jaw" "I had a slight concussion." Patient #4 indicated that he/she was taken to the hospital and when he/she returned back to the facility on 4/3/22, was placed on a separate unit and on 1:1 observation for safety. Patient #4 stated "I didn't even do anything, I was scared for my life."

d. At 2:19 PM, during an interview, Staff #19 indicated that Patient #6 has a long history of aggression and assault behaviors as a result of a traumatic brain injury. Staff #19 indicated that when Patient #6 exhibits assault behavior, within minutes after the assault, he/she is calm, therefore restraints cannot be utilized. Staff #19 also indicated that the treatment team has discussed on multiple occasions placing Patient #6 on 1:1 or 2:1 observation but felt it would only escalate his/her assault behavior. Staff #19 stated the following regarding Patient #6:

(i) "There is no hope for re-direction in the moment."

(ii) "Staff are fearful and make exceptions, so they don't push [him/her] too far."

(iii) "There are no consequences out of fear."

(iv) "We have a limited number of tools/resources at our disposal to protect staff and patients."

(v) "There was greater time between assaults and (patient name) [Patient #6] was about to get Level 3 (Limited Supervision). As of March, [Patient #6] is on Level 1 (Maximum Supervision) because [he/she] can't go more than 2 weeks without assaulting someone."

(vi) A transfer request, for Patient #6, was made to a higher level facility and was declined as other patients took priority.

3. On 4/7/22 12:32 PM, Medical Record #6 was reviewed and revealed that Patient #6 was transferred from another Forensic Center to this facility on 7/27/21 for a less restrictive environment. Patient #6 was adjudicated NGRI (Not Guilty By Reason of Insanity) and is currently on KROL (monitored by a Superior Court) status. Patient #6 has an extensive history of aggression and assault behavior. The Psychology Violence Risk Assessment, completed on admission, indicated a diagnosis of Intermittent Explosive Disorder.

4. From July 2021 to 4/7/22, Patient #6 was involved in the following assault incidents at the facility:

a. On 8/29/21 at 7:48 PM, Patient #6 assaulted Patient #7 resulting in a 3 cm (centimeter) laceration to Patient #7's right earlobe.

b. On 10/11/21 at 9:00 AM, Patient #6 assaulted Patient #8 resulting in a laceration to the lower lip, a closed fracture of the orbital floor and a closed fracture of the nasal bone.

c. On 11/20/21 at 9:06 AM, Patient #6 was involved in fight in which a shank, made out of a toothbrush and tape, fell out of the patient's hand during the fight.

d. On 12/14/21 at 2:25 PM, Patient #6 assaulted Patient #9 resulting in no injuries.

e. On 1/5/22 at 3:15 PM, Patient #6 assaulted Patient #10 resulting in a laceration and fracture of the nose.

f. On 2/9/22 at 10:20 PM, Patient #6 assaulted Patient #7 resulting in a superficial abrasion to Patient #7's bridge of nose.

g. On 2/27/22 at 4:45 PM, Patient #6 assaulted Patient #11 resulting in closed fractures of the right and left nasal bone.

h. On 3/2/22 at 9:00 AM, Patient #6 assaulted Patient #12 while he/she was being placed in restraints by staff, resulting in Patient #12 being transferred to the Emergency Department to rule out facial fracture. Patient #12 sustained a contusion to the face.

i. On 3/16/22 at 7:30 PM, Patient #6 assaulted Patient #7 resulting in no injury and broken eyeglasses.

j. On 3/23/22 at 12:00 AM, Patient #6 assaulted Patient #7 resulting in no injuries.

5. Patient #6 exhibited assault behaviors that have resulted in serious injury and harm to multiple patients on multiple occasions. The patient's plan of care has been ineffective in the mitigation of the aggressive and assault behavior and facility staff are unable to effectively handle the patient's behaviors, which placed all staff and patients on the unit at continued risk for serious injury and harm.

6. On 4/12/22, a review of facility documents between November 2021 to 4/12/22 revealed there were 45 incidents that involved assault on the Holly Hall A Forensic Unit. Twenty-two (22) of the 45 incidents resulted in physical injury.

7. The above findings were confirmed by Staff #2 at the time of the findings.

The above findings resulted in an Immediate Jeopardy (IJ) on 4/12/22 at 12:00 PM, the Chief Executive Officer (CEO) was informed of the IJ and a copy of the IJ template was provided at 4:05 PM. An immediate removal plan was requested at that time.

The facility was unable to provide a removal plan by the exit date, 4/13/22.

Based on staff interviews and review of facility documents, it was determined that the facility failed to maintain a Quality Assessment and Performance Improvement (QAPI) program that implements preventative actions based on data collected for violence behaviors and monitor the effectiveness to ensure patient safety.

Findings include:

The facility failed to implement preventative actions to ensure patient care is provided in a safe setting. (Cross Refer to Tag A-0115, Tag A-0144, and Tag A-0273).

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure its quality assurance program monitored and evaluated the effectiveness of quality improvement activities developed for violence prevention and safety of services.

Findings include:

Reference: Facility policy titled, "Clinical Review Process," dated 1/4/21, states, "...II. Purpose To provide support to the Treatment Team in the treatment of patients with challenging high-risk behaviors and //achieve optimal results by ensuring that all appropriate and available clinical resources are provided to the patient. III. Definition A. Clinical analytic Review Committee (CARC): A committee of administrative leadership staff and other staff as requested who review Single Subject Design Analysis models for the period of Monday 12:00 A.M. from the previous two weeks to 11:59 P.M. Sunday night of the current week and provides names of four patients to be considered for review by the Office of the Medical Director. ... IV. Procedures ...B. Clinical Reviews are scheduled through the Office of the Medical Director on Wednesday and Friday...a Clinical Review is scheduled in response to the following: 1. Any incident resulting in serious injury to the patient or others. ...3. Any patient identified as the aggressor that is involved in three or more assault incidents, regardless of the level of injury, within a rolling 7-day period. 4. To assist the Treatment Team in treating a patient that is exhibiting an increase in high-risk behaviors in which the current course of treatment has not appeared to have been effective. ..."

1. On 4/13/22, the facility's Quality Assurance and Performance Improvement (QAPI) Strategic Plan and activities were reviewed in the presence of Staff #2 and Staff #26. Staff #2 and Staff #26 indicated that the Clinical Analytics Review Committee (CARC), which is documented in the QAPI Plan, was one of the programs developed to mitigate high-risk behaviors such as Patient-to-Patient Assaults.

a. On 4/13/22 at 12:05 PM, during an interview, Staff #27, the Medical Director, indicated that the CARC conducts reviews every Wednesday and Friday. Two reviews are conducted on Wednesday and two on Friday.

b. Review of the Clinical Analytics Scheduled Reviews Report for 2022 revealed the following:

(i) Patient #6 was identified as meeting criteria for the three assaults in a seven day period on 3/2/22, and was scheduled for review on 3/9/22. The report indicated that the review was rescheduled to 3/16/22 due to electrical/technical difficulties.

(ii) On 3/16/22, the report indicated that only one review occurred on the third Wednesday of the month due to the ECMS (Executive Committee Medical Staff) meeting. There was no evidence on the report that Patient #6 was reviewed on 3/16/22.

(iii) Patient #6 was scheduled for review on 3/18/22. The report stated, "Review was canceled (bumped) due to the emergency review identified by administration for (another patient name)." The following justification was provided from the Clinical Review Tracking Log: "The HHA [Holly Hall A] TXTM [Treatment Team] agreed to decline this review based on the following: Medication changes were made and showing efficacy. Pt [Patient] is displaying less anger since the trigger of his anger has been removed. NOTE* an emergency review was done in place of this case."

2. Facility documents indicated that Patient #6 assaulted another patient on 3/16/22 and 3/23/22, both with no injury. On 4/2/22, Patient #6 assaulted Patient #4, unprovoked, resulting in Patient #4 being transferred to the hospital and having multiple facial fractures (right maxillary sinus, right orbit and bilateral nasal bones).

3. Staff #2 and Staff #4 confirmed that Patient #6 had 11 documented assaultive behavior incidents between his/her admission date on 7/27/21 and 4/12/22, and that Patient #6 was never reviewed by the CARC.

4. On 4/13/22, the Violence Prevention Committee meeting minutes for 1/11/22, 2/8/22, and 3/8/22 were reviewed with the following identified:

a. The 1/11/22 meeting minutes indicated that there was a total of 81 Patient-to-Patient assaults throughout the hospital, during the month of November 2021, which was an increase from the 80 assaults in October 2021. Fifty (50) of the assaults resulted in a report of no injuries, 30 were reported with minor injuries, zero were reported with moderate injuries, and one was reported with major injury.

(i) There was a total of 61 Patient-to-Patient assaults throughout the hospital, during the month of December 2021, which was a decrease from the 81 assaults in November 2021. Thirty-three (33) of the assaults occurred with a report of no injuries, 28 were reported with minor injuries, and there were no reported assaults of moderate or major injury.

(ii) The "Resolution" section of the report stated, "Who will take action: No action necessary."

b. The 2/8/22 meeting minutes indicated that there was a total of 69 Patient-to-Patient assaults throughout the hospital, during the month of January 2022, which was an increase from 61 assaults in December 2021. Thirty-nine (39) of the assaults occurred with a report of no injuries, 30 were reported with minor injuries, and there were no reported assaults with moderate or major injury.

(i) The "Resolution" section of the report stated, "Who will take action: No action necessary."

c. The 3/8/22 meeting minutes indicated that there was a total of 60 Patient-to-Patient assaults throughout the hospital, during the month of February 2022, which was a decrease from the 69 assaults in January 2022. Thirty-nine (39) of the assaults occurred with a report of no injuries, one was reported with a minor injury, one was reported as a moderate injury, there were no reported assaults with major injury.

(i) The "Resolution" section of the report stated, "Who will take action: No action necessary."

d. At the time of the survey, there was no April meeting minutes; however, the March data was provided to the surveyors. There were 96 Patient-to-Patient assaults throughout the hospital, during the month of March 2022, which was an increase from the 60 assaults in February 2022. Sixty-two (62) of the assaults occurred with a report of no injuries, 31 were reported with minor injuries, two were reported as a moderate injury, and one was reported as a major injury.

5. On 4/13/22 at 2:30 PM, during an interview, Staff #2 stated that the Violence Prevention Committee reports up to the Provision of Care Committee, who reports up to the Executive Management Committee, who is a branch of the Governing Body. The Executive Management Committee Meeting Minutes for the last 6 months was requested and reviewed. The meeting minutes failed to address violence within the facility, the number of assaults occurring and the actions taken to minimize/mitigate violence.

a. The above finding was confirmed by Staff #2.