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Based on document review, policy review, record review, observation and interview, the hospital failed to ensure measures were implemented to protect all patients who were at risk from physical abuse from other patients.

The findings included:

The hospital failed to implement preventative measure for patients at risk for physical abuse to ensure all patients were free of abuse neglect.
Refer to A 145

Based on policy review, record review, observation and interview, the facility failed to ensure all patients were protected from abuse, neglect and physical harm for 2 of 3 (Patients #2 and 3) sampled patients.

The findings included:

1. Review of the "Assessment of Suspected Abuse" policy revealed, "...3. Adult Abuse or Neglect...the deprivation of services by a caretaker which are necessary to maintain the health and welfare of an adult or situation in which an adult is unable to provide or obtain the services which are necessary to maintain that person's health or welfare...Physical Neglect-characterized by a failure of the caregiver to provide the goods or services that are necessary for optimal functioning or to avoid harm..."

Review of the "Management of Aggressive/Violent Patient" policy revealed, "...ESSENTIAL INFORMATION: 1. Indicators of a patient's potential for aggression or violence include, but are not limited to: A. A history of violence, particularly in the current setting...C. Fearful, suspicious, or paranoid patients, especially when feeling threatened. D. A patient experiencing a manic episode who is likely to be irritable and volatile. E. A patient experiencing confusion, delirium, or withdrawal...Careful observation for, and early intervention in, signs of rising anxiety, and/or escalating behaviors, may defuse a potentially violent situation before it starts..."

2. Review of the Incident Report Summary provided by the Risk Manager on 9/11/17 revealed four (4) physical altercations involving Patient #1 towards Patients #2 and #3, with two (2) occurring on 6/16/17, one (1) on 6/17/17 and one (1) on 6/23/17.

3. Medical record review revealed Patient #1 was admitted to the hospital's geriatric psych unit on 5/30/17 with the diagnosis of Unspecified Dementia with Behavioral Disturbance.

Review of the patient's "BH Psychiatric History and Evaluation" for the 5/30/17 admission revealed the justification for hospitalization to be, "...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..." The evaluation revealed, "...Pt is 70 year old female with history of dementia, schizoaffective disorder, anxiety disorder nd [and] MDDO [Major Depressive Disorder]. Pt is experiencing increased confusion and agitation. Pt slapped another resident several times for looking at her. This is the second altercation patient has experienced lately. Pt is verbally aggressive towards others and responding to unseen others. Pt is withdrawn, isolative, and demands to be left alone. Pt is paranoid and suspicious of others. 'Get away from me, Stop watching me, I will kill you.' ...displaying combative behavior towards staff and peers...cursing at other residents...very difficult to redirect and talking to voices only she can hear...refusing meds and care...remains impulsive and labile. Extremely impaired insight and judgement....refusing to sleep or eat...Multiple [name of this hospital] admissions..."

Medical record of the Behavior Intervention Response Plan (BIRP) notes, physician's orders and incident report summary revealed the following:

6/3/17- The BIRP note revealed at 5:32 AM "...Yells with roommate...[4:00 PM]...Labile, suspicious of others, oppositional..."

6/4/17- The BIRP note revealed at 2:00 PM "...Verbally aggressive to peers, swinging fists at them...Attempts at redirect unsuccessful including room change..."

6/5/17-The BIRP note revealed at 3:21 PM "...Impulsive...[2:23 PM] Patient agitated, combative and yelling obscenities at staff and other patients...[at 3:47 PM] cussing at staff/peers, yelling out at staff/peers, up and down hall cussing at everybody...Encourage to attend grp [group], and socialize with staff/peers..."

6/8/17- The BIRP note revealed at 1:39 PM "...exhibiting aagitated [agitated] behavior as eviednced [evidenced] by yelling at staff and other patients in the hallway...continue to monitor patient...redirect as needed." There was no documentation of other interventions to ensure patients' safety.

6/10/17- The BIRP note revealed at 3:30 AM "...quite loud and verbally abusive...continue...q [every] 15 minute checks...[11:33 AM]...exhibiting aggressive oppositional behavior...yellin [yelling] at other patients, cursing in the hallway and refusing to go to her room...Patient was taken to her room by wheelchair...Will continue to monitor patient..." There was no documentation of other interventions to ensure patients' safety.

6/11/17- The BIRP note revealed at 12:13 PM "...exhibiting impulsive behavior...Will continue to monitor patient..." There was no documentation of other interventions to ensure patients' safety.

6/13/17- The BIRP note revealed at 1:26 AM "...Came to nurses station in wheelchair with pad over her...Redirected to room to put on close [clothes]...[10:58 AM]...exhibiting inappropriate behavior...coming out into the hallway with there [her] gown pulled up...Will continue to monitor patient..." There was no documentation of other interventions to ensure patients' safety.

6/16/17- The BIRP note revealed at 1:59 AM "...easily agitated when her peers gets near...impulsive, curses some of the residents [patients]...Q 15 min checks..."

The incident report summary revealed on 6/16/17 at 1:00 PM in the unit dayroom, "... [Name of Patient #1] grabbed [name of Patient #3] by the hair pulling and scratching [name of Patient #3's] face. [Name of Patient #1] was removed from unit dayroom to her room and in process attacked staff member..." Patient #1 was given medication to calm her down. "... [Name of Patient #3] had small abrasion to L [left] side of face..."

The BIRP note revealed at 1:28 PM, "Call placed to [name of physician]...patient with increased aggression, cursign [cursing] at staff, trying to gett [get] out of the doors of the unit...[at 4:21 PM]...yelling out and hitting other patient, cussing out the other pt and staff...q 15 min checks, Encourage to socialize with staff/peers...Cont POC."

The BIRP note revealed at 7:04 PM "pt scratched another pt in the face and grabbed the staff..."

The incident report summary revealed on 6/16/17 at 8:00 PM in the unit hallway, "...name of Patient #1 pulled [name of Patient #2] by hair and causing injury to bridge of nose...Abrasion was cleaned and assessed...[name of Patient #1] directed to room."

The BIRP note revealed at 11:46 PM, "...Sleeping off and on after attacking a resident [Patient #2] by pulling her hair and cause a small abrasion to he [the] resident nose bridge...Q 15 minutes check in progress. Patient redirected to her room...Patient confused...Will continue with care and treatment."

6/17/17 - The incident report summary revealed on 6/17/17 at 3:15 PM in the unit hallway, "... [Name of Patient #1] scratched [name of Patient #2] on face under R eye and eye glasses were broken. [Name of Patient #2] upset... [Name of Patient #1] provided a PRN [medication] and removed to her room..." There was no documentation of the 6/17/17 behaviors in the behavior notes.

6/18/17- The BIRP note revealed at 2:14 AM the patient was "...Impulsive..." and irritable when redirected. At 2:13 PM "...Pt is angry and agitated...Will continue to monitor." There was no documentation of other interventions to ensure patients' safety.

6/19/17- The BIRP note revealed at 3:53 PM "...encourage to socialized [socialize] with staff AND PEERS..."

6/22/17- The BIRP note revealed at 1:40 PM "Patient in hallway stripping clothes and yelling, 'everybody has seen black meat'...[at 3:02 PM]...Patient is exhibiting oppositional and aggressive behavior as evidenced by yelling at other patients going by in the hallway without provocation...Will continue to monitor patient and redirect as needed." There was no documentation of other interventions to ensure patients' safety.

6/24/17- The BIRP note revealed at 2:00 PM, "Report by staff that patient has been aggressive and requires additional monitoring...to place the patient on 1:1 observation."

Review of the incident report summary revealed on 6/23/17 at 11:45 PM in the unit hall near the nursing station, "... [name of patient #2] was noted as standing near nursing station when [name of Patient #1] rolled by...and grabbed her [Patient #2] by the hair, grabbing her glasses off her face and breaking eye glasses...placed on 1:1 [observation]."

Review of the 6/24/17 physician's order revealed 1:1 observation of the patient was ordered at 2:09 PM, over 12 hours after the incident occurred. There was no documentation other measures were implemented to ensure the safety of Patient #2 and all other patients.

6/25/17- The BIRP note revealed at 9:21 AM, "...Behavior-argumentative, yelling, aggressive towards other patients...[at 11:37 AM]...cursing, disruptive in group and hitting at current 1:1 staff."

7/1/17- The BIRP note revealed at 1:00 AM, "...Yells, curses at, and hits staff. Voices dislike of white people. Very impulsive..."

7/2/17- The BIRP note revealed at 12:56 AM, "...Patient do not like it when other patients have behavior problems. She would yell out loud to the patients to be quiet..."

7/4/17- The BIRP note revealed at 5:15 AM, "...Impulsive. Easily agitated. Yelled at her roommate so much that she [roommate] was terrified of her and had to be moved..."

7/7/17- The BIRP note revealed at 11:18 PM, "...up yelling and screaming at staff and other pt...q 15 min chec [checks]..."

7/8/17- The BIRP note revealed at 10:45 AM, "...Behavior...will act out around white females and yell racist comments..."

In an interview in a conference room on 9/11/17 at 10:30 AM with the Discharge Planner (DP), the DP stated she "was familiar with this patient. She [Patient #1] has been here many times." The DP stated Patient #1 dislikes white people.

4. Medical record review revealed Patient #2 was admitted to the hospital's geriatric psych unit on 6/1/17 with the diagnosis of Severe Recurrent Depressive Mood Disorder.

Review of the patient's "BH Psychiatric History and Evaluation" for the 6/1/17 admission revealed the justification for hospitalization to be the same as Patient #1's. The evaluation revealed, "...Hallucinations, delusions, agitation, anxiety, depression resulting in significant loss of functioning...Dangerous to self, others or property with need for controlled environment. Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..." The evaluation revealed, "...Legally mandated admission...Chief Complaint...rambling nonsensically...Patient is a 61 year old WF [white female] admitted with increased confusion and agitation. Poor sleep/appetite, unable to function...reviewed past history per social work, [name of hospital] and outside records..."

Review of the BIRP notes revealed the following:
6/2/17- "...pacing the hall trying to escape from the front door...started beating on the glass window..."

6/6/17- "...anxious agitated behavior behavior...banging on glass partition and door of unit. Yelling out when staff attempt to redirect her..."

6/7/17, 6/8/17, 6/9/17, 6/10/17, 6/11/17, 6/12/17, 6/13/17, 6/14/17 and 6/15/17 - Patient #2 had the documented behaviors of "pacing" in hallway, room or in and out of other patient rooms.

6/17/16- At 12 midnight, "...Earlier patient was attacked. hair pulled and sustain a small size abrasion on her nose bridge..." At 3:48 PM, "...Walk the hall most of the day wondering in other patients room..." At 6:34 PM, "Pt was hit in the face by another patient. First aid was given washed and cleaned. The area is located under the right eye...about 2 to three inches long under her right eye..."

6/18/17- At 12:51 PM, the patient was pacing the hallway, going in and out of other patient rooms, confused, talking to herself and laughing out loud most of the day. At 7:30 PM, "Nurse spoke with [name of Patient #2's] daughter, which seemed to be very upset. She had some concerns about her mother's eye glasses..."

6/19/17, 6/21/17, 6/23/17, 6/25/17, and 6/26/17- The patient had multiple pacing episodes. On 6/23/17 the note revealed, "...Patient pacing hallway. Not following instructions very well. Physically touches other patients..."

5. Medical record review revealed Patient #3 was admitted to the hospital's geriatric psych unit on 6/14/17 with the diagnosis of Unspecified Dementia with Behavioral Disturbance.

Review of the patient's "BH Psychiatric History and Evaluation" for the 6/14/17 admission revealed the justification for hospitalization to be the same as Patient #1 and #2. The evaluation revealed, "...Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment, Emotional or behavioral conditions and complications requiring 24 hour medical and nursing care..." The evaluation revealed, "...64 yo [year old] WF [white female] with increased confusion and combativeness at nursing home...unable to answer questions or follow conversation. Wandering aimlessly around the unit. Was not able to state her name. Unable to function...

The incident report summary revealed on 6/16/17 at 1:00 PM in the unit dayroom, another patient (Patient #1) grabbed Patient #3 by the hair and scratched Patient #3's face, leaving an abrasion to left side of Patient #3's face. There was no documentation in Patient #3's record of this attack from Patient #1.

6. In an interview on 9/25/17 at 1:20 PM the DP stated the hospital uses 114 beds for psychiatric patients and 8 for Med-Surg patients.

Observations on 9/25/17 at 1:30 PM on the locked senior psychiatric unit revealed a hallway. On the left side of the hallway was a nursing station and an activity/day room. Both sides of the hallway had doors which entered into the patient rooms. There were patients sitting in chairs and wheelchairs up and down the hall in the doorways. There was no observation of staff providing interventions/activities with the patients sitting in the hallway.

Intakes: TN00042056, TN00042533

Based on unit bath/shower schedule, medical record review and interview, the facility failed to provide a bath/shower to 1 of 3 (Patient #6) patients reviewed.

The findings included:

Review of the Senior Care Unit (SCU) Bath/Shower Schedule revealed Patient #6 was scheduled to have a bath/shower on Monday, Wednesday and Friday of each week on the 11:00 PM to 7:00 AM shift.

The "Shower Schedule Rotation All Shifts" form revealed, "CNA [Certified Nurse Assistant] assigned on the date/shift will complete a shower/bed bath and also wash/dry removed clothing. Clean clothing or a gown will be placed on the patient until the washed clothing is available. PRN [As Needed] showers should also occur on a daily basis."

Review of the CNA Flowsheets from 9/5/17 through 9/27/17 revealed Patient #6 received a bath on 9/9/17 (Saturday), 9/10/17 (Sunday), 9/12/17 (Tuesday). It was documented Patient #6 received a total bath on 9/19/17 (Tuesday) and a bed bath on 9/20/17 (Wednesday). There was no other documentation the patient received a bath/shower per the schedule.

During an interview in the conference room on 10/5/17 at 2:45 PM, the Discharge Planner stated she could not find documentation the patient (Patient #6) had a bath per the scheduled.

During an interview in the conference room on 10/5/17 at 2:55 PM, the Senior Care Unit Nurse Manager stated, "We do not keep a copy of the CNA Daily Assignment sheet. There is no documentation she [Patient #6] received a bath [except days noted by the surveyor]."