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Based on medical record review, staff interview, and patient sitter orientation documentation review, the facility failed to ensure appropriate safety measures were in place to protect patients from physical abuse for 1 of 8 sample patients (#3). This failure resulted in significant harm to patient #3, which required emergency medical stabilization, and subsequent air transport to an out of state trauma center. The findings were:

Refer to A-0145 for facility failure to ensure patient #3 was kept safe from physical abuse, which resulted in significant harm.

Based on medical record review, staff interview, and patient sitter orientation documentation review, the facility failed to ensure appropriate safety measures were in place to protect patients from physical abuse for 1 of 8 sample patients (#3). The findings were:

Review of the Registration Admission form for patient #3 showed s/he was admitted to the Lander Campus ED on 11/19/20 at 5:48 PM. Review of physician documentation dated 11/19/20 at 9:24 PM showed the patient had been evaluated by a physician and the physician did not feel the patient was appropriate for discharge at that time.

Review of the Registration Admission form showed patient #2 was admitted to the Lander Campus ED on 11/25/20 at 1:16 AM with complications with traumatic brain injury. Review of physician documentation dated 11/25/20 at 2:05 AM revealed the following: "...[Patient #2] began acting very bizarrely about 5 days ago and tonight [s/he] was found laying outdoors naked by [the patient's spouse]. [The patient] was confused and acted aggressively toward [the patient's spouse], which was very unusual. [The patient] put a sheet over [the spouse's] head and put [the spouse] in a choke hold briefly. [The patient's spouse] asked [him/her] to stop and [s/he] did..." Review of a 11/25/20 Psychiatric Evaluation from 4:32 AM through 4:55 AM showed altered mental status as the reason to conduct the evaluation. The recommendations were for involuntary inpatient admission for further observation and treatment. In addition, Haldol (antipsychotic) 5 milligrams and Ativan (antianxiety) 2 milligrams were ordered for either oral or intramuscular injection every 6 hours as needed for agitation. The review showed neither medication was administered. Review of a nurse's note dated 11/26/20 at 3:06 AM revealed, "...Patient wandering around to other rooms. Patient redirected by security." A subsequent 11/26/20 nurse's note timed 3:21 AM revealed, "...Patient out in hall and grabbed security's tray stating [s/he] needed it in the room, security to try to deescalate patient, MD made aware and at bedside, patient calm at this time." Review of nurse's notes and physician documentation showed no notable documentation until an 11/26/20 Disposition Summary timed 9:20 AM which revealed that a discharge was ordered for the patient to go to jail with police, and the patient had discharge diagnoses of psychosis and assault of a hospital patient. No details of the assault were documented in the patient's nurse's notes or physician documentation.

The following concerns were identified:

1. Review of physician documentation dated 11/26/20 at 9:22 AM showed patient #3 was physically assaulted by patient #2, which caused patient #3 severe trauma: "ED course: Patient was resting in [his/her] ER [emergency room] bed 1 when the patient in bed 2 [separate rooms] ran in [his/her] room and gouged both [his/her] eyes with [his/her] thumbs. R [right] eye totally avulsed 1 eye swollen with loss of vision and diffuse scleral hemorrhage as well." Review of physician documentation dated 11/26/20 at 9:24 AM revealed, "Eyes: R [right] eye completely avulsed optic nerve pulled out, arterial bleeding controlled with pressure. 1 eye with lat [lateral] glaze, pupil sluggish, medial scleral hemorrhage, patient cannot see out of either eye." Subsequent physician documentation showed the patient was given stabilization care at that time, and a note dated 11/26/20 at 10:05 AM showed the patient had bilateral eye trauma with assault, and was being transferred to a higher level of care in critical condition.

2. Review of a nurse's note dated 11/26/20 at 9:27 AM revealed, "Mechanism of injury: Assault with hands by the patient from room 2 attacked [patient #3] and removed [his/her] right eye with [his/her] hands and it would appear that [s/he] attempted to remove the left as well. Upon hearing the commotion, [RN #2] ran into the patient's room and pulled the room 2 psych patient off of the patient. The ER sitter grabbed the room 2 patient, but was struggling to subdue [her/him]. This RN took physical control over the room 2 patient using joint locks and secured [him/her] to the ground. The ER staff and [primary physician] immediately rendered aid to the patient and moved [the patient] to Trauma room-1...Eyes-The right eye is dislodged from the socket and is hanging down on the right cheek with controlled bleeding at this time. There is notable swelling of the socket. There is scleral hemorrhage of the medial left eye. The patient reports decreased vision in the left eye..."

3. Interview with RN #3 on 12/4/20 at 10:45 AM showed the facility had security at night, but not on the day or evening shifts. RN #3 confirmed the facility cared for violent patients, and the expectation was to contact the local police if security was not on duty. The RN stated the general response time for local police was between 5 and 10 minutes. The RN stated there was a 'panic button' under the main nurse's desk in the ED to notify police if needed, but she had never seen or used it. The RN also stated the sitters were to call the nurse if a patient became agitated, and sitters were not trained to handle violent patients.

4. Interview with sitter #1 on 12/4/20 at 1:50 PM showed he was the sole sitter for both patients #2 and #3 on 11/26/20 at the time of the incident, and he had started at 7 PM the previous evening. He stated his primary job at the facility was in central sterile supply, though he was on the facility sitter list and had taken the sitter test. He stated his qualification to be a sitter for a potentially aggressive patient was that he had been an emergency medical technician until 2015, when his license had lapsed. He stated he followed the documented sitter guidance when sitting for patients, and sometimes he was 1:1 and sometimes 1:2. When 1:2, he would be located in the hallway in order to monitor both patients simultaneously. He stated that on the morning of 11/26/20 at around 9 AM, without warning, patient #2 dashed out of his/her room and entered the room of patient #3. Patient #2 jumped on the bed on top of patient #3 and was shouting incoherently at patient #3 and attacking him/her. The sitter shouted for assistance and made unsuccessful attempts to remove patient #2 from patient #3. Other staff arrived, and when RN #1 arrived, he was able to wrestle patient #2 to the floor. However, there was obvious blood from patient #3's face and s/he was clearly injured in both eyes. Other staff and the physician rendered aide to patient #3, and the house supervisor arrived and took over keeping patient #2 on the floor until the police arrived moments later, and took patient #2 into custody.

5. Interview with RN #1 on 12/7/20 at 1:50 PM showed he was the nurse for patient #3 on 11/26/20 when the incident occurred. Patients #2 and #3 were not the only patients in the ED at the time. There was 1 sitter for two patients who were admitted involuntarily. RN #1 stated that the sitters were not trained to handle aggressive patients, and would call the nurses if a patient became aggressive. The RN stated the ED staff were not provided specialized training for handling physically aggressive patients, security was only provided on the night shift, and the security routinely consisted of maintenance staff without specialized training on how to handle physically aggressive patients. At the time of the incident, RN #1 was with RN #4 in another room, and they heard a commotion. When RN #1 arrived at patient #3's room, patient #2 was attacking patient #3 and there was obvious injury to patient #3's face and eyes. After subsequently holding patient #2 to the floor, the house supervisor arrived and took over containment of patient #2, and RN #1 then assisted the physician with emergency care of patient #3, first transferring the patient to the trauma room, then transferring the patient via a medical flight team from the ED to be taken to an out of state medical center for a higher level of care.

6. Interview on 12/4/20 at 1:40 PM with the ED physician who cared for patients #2 and #3 on 11/26/20 at the time of the incident showed he started work at the shift change at 8 AM on 11/26/20, and there were other patients in the ED in addition to the 2 patients in the incident, so staff were busy. He stated patient #2 did not show any signs of aggression leading up to the sudden change in his/her behavior. He further stated he had concerns related to involuntary psychiatric patients being kept in the ED, and the ED not being equipped with a locked room to protect other patients from aggressive patients, and said that the ED at present was not reliably safe to hold aggressive patients. He confirmed his notes of the events of 11/26/20 for the incident between patients #2 and #3, and he stated the staff rapidly provided emergency care to patient #3 and transported him/her to a higher level of care via air transport. He stated the local police were called and arrived in minutes, and he wrote the order to have them take patient #2 to jail for the safety of other patients and staff.

7. Interview with the CNO on 12/4/20 at 4:20 PM revealed the use of sitters for involuntary patient admissions could be 1:1 or 2:1 based on the risk determination of the ED staff. She stated patient #2 and patient #3 were considered low risk for aggression until the incident on 11/26/20, so one sitter had been utilized for both patients.

8. Review of the "Patient Sitter Orientation" dated October 2017, showed, "In certain circumstances, you may be required to take action to prevent a patient from harming themselves prior to the nurse's arrival. An example of this may be holding the patient's hand to prevent them from pulling out a tube or line. If the patient is doing something that may cause harm (e.g. climbing over the bed side rails), attempt to stop these actions by giving brief, clear instructions. Repeat this up to 3 times (over one minute) in a firm, yet quiet manner. Be sure that you have the patient's attention. Make eye contact when possible. If the patient persists in this harmful behavior, contact the nurse right away." Review of the corresponding "Competency Assessment Sitter Expectations" showed no training for the sitter regarding patient aggression other than identification of behaviors that may predispose a patient to violent/destructive actions or increased agitation. Review of the corresponding "Patient Sitter Competency Quiz" showed 5 questions. The only question related to an emergency situation was as follows, "If an emergency situation occurs, a sitter should stay with the patient and call for help with the call light or call for help."