HospitalInspections.org

Based on medical record review, video surveillance review, facility documents, staff interviews, and review of facility policy, it was determined that the facility leadership failed to protect patients from all forms of abuse when two patients (P) (P#1 & P#3) of five (P#2, P#4, & P#5) sample patients were abused by one patient (P#2).


Findings include:


A review of P#1's medical record revealed that she was admitted to the facility on 3/13/25 with major depressive disorder (mental disorder characterized by a persistent low mood, loss of interest or pleasure in activities). Review of nurse note dated 3/13/25 at 6:25 p.m. revealed P#1 was sent to ER (emergency room) after being attacked by peer. The peer punched P#1 in the head and nose for unknown reasons; nurse manager was on the unit when the incident occurred.


Review of nurse note dated 3/13/25 at 9:00 p.m. revealed spoke to ER charge nurse for acceptance, full report given. P#1 was accompanied by a staff member at her side. Patient was calm and cooperative upon her transfer. No distress upon her transfer.


A review of video surveillance dated 3/13/25 at 6:13 p.m. revealed the following:
00:12 females standing and sitting at the end of the hallway
00:38 RN DD walks out of P#1's room with linen in her hand
00:58 RN DD unlocks door to linen closet
01:41 P#2 runs into P#1's room swinging her arms
01:43 MHA CC runs behind P#2
01:48 all staff heading to P#1's room


Review of P#2 incident report #25-67272 revealed the following:
A. Date of Incident: 03/12/2025 Time: 9:45 p.m.
B. Incident Type: aggression patient towards patient.
Comments: "At 9:45 p.m. patient get agitated because the other patient sreamed [sic] in another room, patient still on 1:1 (one on one) got out of her room and physically and agresively [sic] punched the other patient in her face multiple times. Other patient face noted with redness and sting of blood on her nose, but no active blleding [sic] noted on her nose."


Review of P#1 incident report #25-68212 dated 3/13/25 revealed the following:
A. Date of Incident: 03/13/2025 Time: 6:25 p.m.
B. Incident Type: aggression by another patient.
I. Treatment or Intervention Given: Emergency Room.
Comments: " Patient was sent to the ER (emergency room) after being attacked by her peer. Her peer punched her in the head and nose ...."


Review of P#2 incident report #25-68242 dated 3/13/25 revealed the following:
A. Date of Incident: 03/13/2025 Time: 6:25 p.m.
B. Incident Type: aggression patient towards patient.
H. Injury. Self-inflicted.
Comments: "Patient attacked her peer for unknown reasons. She punched her in the head forehead area and nose. Code 1 was called. Staff separated her from her peer. Patient's left index finger was slightly swollen. First aid applied. Good range of motion. Internist formed-X-ray orders received and placed. All other appropriated notifications made."


Review of P#1 incident report #25-71711 dated 3/17/25 revealed the following:
A. Date of Incident: 03/13/2025 Time: 6:28 p.m.
B. Incident Type: Change in Condition.
D. Type of Injury: Bruise.
H. Injury caused by other patient.
N. Physician Response. Treatment required.
Comments. "Pt presented with c/o (complaints of) headache after being hit by another patient. No obvious injury beyond slight pinkness to face region. No lacerations or cuts. Patient remained Alert Ox3, verbalizing needs, ambulating without difficulty. Took water without difficult. However anxious. Addendum 3/18/25 8:51 a.m. : Pt.was discharged from (the acute care hospital) back254 home with mother. Dr at (acute care hospital) consulted with treating inpatient DR on discharge plan. No injuries identified from ED visit."


An interview was conducted with Registered Nurse (RN) BB on 3/24/25 at 4:15 p.m. in the administration conference room. RN BB stated that she recalled P#1 and P#2 and the incident that took place on the adolescent unit earlier this month. RN BB stated that she did not witness the altercation; however, she completed the paperwork to transfer P#1 to the hospital after the altercation with P#2. She continued to explain that she was given detailed information from RN DD who witnessed the assault. RN BB continued to explain that RN DD told her that there was a verbal exchange between P#1 and P#2 in the dayroom a few minutes earlier and according to RN DD, she wanted to removed P#1 from the situation and escorted her to her room. RN BB recalled that RN DD stated that P#2 followed her (RN DD) and P#1 to P#1's room and attacked P#1 for no reason. RN BB stated that as soon as she heard the altercation she ran out of the back room to see what was going on and immediately got P#1 out of the room to keep her safe and away from P#2. RN BB stated that she immediately assessed P#1 and advised the nurse manager that she needed to go to the hospital. She continued to explain that she notified P#1's mom of the assault.


An interview was conducted with Assistant Director of Nursing (ADON) AA on 3/25/25 at 11:00 a.m. in the administration conference room. ADON stated that she did recall the incident that involved P#1 and P#2 on 3/13/25 on the adolescent unit. She continued to explain that on the day of the incident, she was on the unit making her rounds and noticed P#1 in the dayroom area conversing with her peers. P#2 was on a one-to-one, was also in the dayroom area. ADON continued to explain that P#2 was on one-to-one due to her history of seizures, not because of her aggression. She continued to say that P#2 had several aggression incidents while at the facility and it had been difficult to regulate this patient. She continued to explain that she was notified of the altercation soon after it occurred and advised RN BB to contact P#1's guardian as well as the physician regarding the assault. ADON continued to explain that she was advised that P#1's physician requested that she (P#1) be sent to the hospital to be assessed. ADON stated that the charge nurse on duty was responsible for making nursing assignments based on the acuity.


An interview was conducted with Registered Nurse (RN) DD on 3/25/25 at 3:00 p.m. in the administration conference room. RN DD stated that she did recall P#1 and the incident that occurred between P#1 and P#2 earlier this month. She continued to explain that on the day of incident she was working on the adolescent unit when she noticed all the girls in the dayroom talking among themselves. She continued to explain that she noticed P#2 verbally teasing P#1 and due to the verbal teasing she decided to move P#1 to her room away from P#2. RN DD stated that she continued to keep her eye on P#2 because she had a history of physically attacking and assaulting patients and staff. She continued to explain once she moved P#1 to her personal room, she walked out to get fresh linen to make her bed. She continued to explain that she instructed P#1 to stay in her room until she returned because she could see P#2 was still in the dayroom and she was concerned for P#1's safety. RN DD stated that by the time she walked into the linen room, she could hear a commotion coming from P#1's room and she ran down the hallway along with other staff to break up the fight. RN DD stated when she entered P#1's room she witnessed P#2 hitting P#1 on her head. She continued to explain that MHA CC was already in P#1's room attempting to break up the fight and eventually removed P#2 from P#1's room. RN DD stated that she immediately assessed P#1 and gave report to ADON. She continued to explain that she gave an account of what happened to RN BB who was making contact with P#1's guardian and the physician. RN DD stated that the physician ordered to have P#1 go to ED for further assessment.


An interview was conducted with Mental Health Assistant (MHA) CC on 3/25/25 at 3:35 p.m. in the administration conference room. MHA CC stated that she did recall the incident that occurred between P#1 and P#2 on the adolescent unit. She continued to explain that she was next to P#2 all day on the day of the incident. MHA CC stated that P#2 required a staff member to remain with her at all times because of her spontaneous, erratic behavior. She continued to explain that before the incident she could recall sitting next to P#2 in the dayroom and P#1 had just arrived to the unit earlier in the day. MHA CC stated that P#2 was verbally teasing P#1 for no apparent reason. MHA CC stated that RN DD seemingly noticed something too because she removed P#1 from the dayroom and escorted P#1 to her personal room on the unit. She continued to explain that at one point all the girls were in the dayroom area standing up talking among themselves and as she stood next to P#2, P#2, unprovoked, took off running into P#1's room hitting P#1. MHA CC stated as soon as P#2 started to run towards P#1 she started running after her, but P#2 made it, into P#1's room in enough time to hit her a few times in the head. MHA CC stated that this is the reason P#2 is required to have one-to-one precautions because she has a history of reacting violently without warning and without reason.


A review of the facility's "Patients' Right and Responsibilities" policy, Policy number RI.005, last reviewed 10/2022 revealed II. List of Rights. A. Without limitation patients shall be entitled to: Care in a safe and sanitary setting. Be free from neglect, exploitation; verbal, mental, physical, sexual abuse, and all forms of abuse, harassment and corporal punishment.