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Based on interview and document review, the hospital failed to provide care in a safe setting when the hospital staff failed to identify and initiate assault precautions on a patient who had a history of violent threats, and had threatened the life of her peers for 1 of 10 patients reviewed (P2), when P2 attempted to choke P1.

Findings include:

Medical Record review revealed P2 was admitted to the hospital on 1/19/19, as a transfer from another hospital with diagnoses that included disruptive mood dysregulation disorder, intentional drug overdose, post traumatic stress disorder, and reactive attachment disorder. P2 was initially admitted to a medical unit at the hospital for treatment of an intentional overdose. P2 was later transferred to a mental health unit. P2's admission orders included every 15 minute checks for safety.

Review of P2's Physician note, dated 1/19/19, revealed: P2 initially presented to the hospital via EMS. The patient had recently been released from a hospital in Fargo after threatening to stab others. The patient indicated that she had another personality, with another name (X), who was responsible for the threats and that X, "Tells me to do bad things." P2 stated that X is the one who broke into her group home's medication closet and took the overdose. When asked, P2 stated she was not currently suicidal or homicidal, but also stated that she could not speak for X.

Despite the above, P2's initial nursing assessment dated 1/19/19, revealed that the patient was assessed by nursing staff as having "no risk factors" for violence on admission.

Medical record review revealed P1 was admitted to the hospital on 1/11/19, with diagnoses that included bipolar disorder. P1's admission physician orders included every 15 minute checks for safety.

A review of hospital progress notes and nursing flow sheets revealed staff assessed P2 for suicide and homicide ideation each shift, as they do for all patients.

A Nurse Practitioner note dated 1/23/19, revealed P2 denied being suicidal or homicidal, but admitted that X was "aggressive and dangerous."

A nursing progress note dated 1/26/19, revealed P2 stated she had begun feeling anxious, and her multiple personalities had been "coming out and talking to me today."

A nursing progress note dated 1/28/19, revealed P2 was cursing and escalating. P2 was asked to go to her room, which she eventually agreed to, however she escalated in her room stating, "If those two bitches don't stop whining, I'm fixing to fuck them up for good." P2 was directed to go to her room, and P2 stated "Fuck that." A show of support was called, and P2 went to the quiet room but stated, "X doesn't like you," and was walking with clenched fists. P2 was eventually cooperative with taking PRN medications.

A physician note dated 1/29/19, revealed P2 threatened to hurt her peers.

A Mental Health Associate note dated 2/4/19, revealed P2 stated she was angry and sad related to a situation on the unit. P2 denied suicidal or homicidal ideation but stated, "Sometimes when I'm upset I can't ask for help."

A nursing note dated 2/5/19, revealed P2 became upset by comments of a peer. P2 was agitated. P2 threatened to kill a peer. P2 requested a PRN medication, but then stated the request must have come from one of her other personalities, and then declined the medication. P2 stated, "It's really hard, I'm just triggered. I don't know what to do."

A physician note dated 2/6/19, revealed on 2/6/19, after dinner P2 came up behind a peer, P1 and grabbed P1 around the neck in a choking manner. Staff intervened and P2 immediately let go. The total time for the attempted strangulation was less that 10 seconds. P2 was placed in seclusion. P2 stated she was in a dissassociative state at the time of the incident and did not remember it.

There was no evidence that P2 was placed on assault precautions on admission or at any time until after P2 attempted to choke P1 on 2/6/19.

During an interview with registered nurse (RN-C) on 3/12/19, at 9:50 a.m. RN-C stated she investigated the choking incident between P1 and P2. RN-C stated neither patient was injured in the incident. RN-C was not aware of any previous altercations between P1 and P2 prior to this incident.

During an interview with P2 on 3/12/19, at 10:35 a.m. she stated she was in seclusion for awhile because the staff told her she choked another patient. P2 stated she has nine different personalities, and one of those personalities must have done this because she did not remember anything about it. P2 stated sometimes another personality takes over and does things that she is not aware of.

During an interview with P1 on 3/12/19, at 11:00 a.m. P1 stated that on 2/6/19, P2 was sitting behind her in the lounge. Suddenly P1 heard P2 talking and her voice changed, and she stated "I'm not (P1), I'm X, and I'm going to kill her." Then P1 felt hands around her neck choking her. P1 pried P2's hands from her neck and staff intervened.

During an interview with RN-I on 3/12/19, at 2:05 p.m. he stated that he was caring for P2 on 2/6/19, when the choking incident occurred. He stated that P2 was not on assault precautions, and he was not aware P2 had a history of violence or threats to peers.

During an interview on 3/12/19, at 2:30 p.m. Mental Health Associate-J (MHA-J) stated she was working on 2/6/19, during the incident when P2 attempted to choke P1. MHA-J stated she was not aware of any violent threats P2 had made towards any peers prior to this incident. After the incident, P2 blamed another personality, X, for the incident.

During another interview with RN-C on 3/12/19, at 1:45 p.m. she stated that when a patient comes onto the unit with a history of violence or threats of violence, usually three things happen, 1. There is a staff alert put in Epic (the electronic medical record) to make staff aware. 2. There is a nursing communication order. 3. The patient is placed on assault precautions. RN-C had no explanation as to why this did not occur for P2 prior to 2/6/19.

Although a policy related to the use of assault precautions was requested, none was provided. This writer was referred to the vulnerable adult policy. That policy was reviewed and lacked direction related to the initiation of assault precautions when a patient has a history of or is threatening physical harm to staff or other patients.