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Based on review of 13 medical records, policies and procedures, interviews with staff, and video surveillance footage, the hospital failed to protect 1 out of 13 patients reviewed (Patient #12) from patient-to-patient physical abuse and placed 2 out of 13 patients (Patients #2 and #4) at risk for experiencing patient-to-patient physical abuse, through a failure to utilize appropriate preventative measures, such as hospital procedure for one-to-one observation and non-physical intervention techniques.

The findings include:

The surveyor reviewed the facility's policy "Abuse and Neglect Reporting and Treatment," last revised 2/7/2020, which defined abuse as, "The sustaining of any physical or mental injury by a vulnerable adult as a result of cruel or inhumane treatment or as a result of a malicious act by any person."

The surveyor also reviewed the facility's policy, "One-to-One Patient Supervision," last revised 6/23/2022, which stated "Constant nursing supervision will be provided to all patients on one-to-one supervision. This will promote the safety and welfare of the patient, facilitate prompt intervention for elopement/elopement attempt, maintain the therapeutic environment, and reduce serious destruction by a patient who is out of control ...The nursing staff member assigned to perform one-to-one supervision must be within arm ' s length at all times and accompany the patient to all activities and/or programs."

Patient #12 (P12) was a minor patient who was admitted to the facility for treatment of a behavioral health condition. P12 was recently admitted to the facility at the time of the survey. On day 8 of P12's admission, P12 was physically assaulted by patient #11 (P11).

Patient #11 (P11) was a minor patient admitted to the facility for treatment of behavioral health issues. On day 14 of P11's admission, a code green (behavioral health emergency which required additional assistance from the facility's security staff) was called for P11's physical assault of P12.

During onsite review of video surveillance footage on April 13, 2023 at 2:35 pm, the surveyors noted the following:

Prior to the code green response, P11 was seen via video surveillance footage, displaying aggressive body language via hand gestures and posturing toward patient #12 (P12). The two patients were observed in the day room on the unit, sitting next to one another.

The facility's staff, including P11's one-to-one observer (a unit staff member assigned to always remain within a predetermined distance of a patient), was seen removing P11 out of the day room and closing the door; thus, prohibiting P11 from entering the day room to engage in further discourse with P12.

Outside of the day room, P11 was observed pacing the unit and looking through the day room door's window. Subsequently, P11 regained access to the day room, after a staff member opened the door, allowing P11 entrance. The surveyors observed no attempt by hospital staff to deescalate P11 prior to the re-entry to the day room. There were no attempts to divert P11's attention to another activity or take P11 to another location after the staff noted that P11 was agitated from his/her interaction with P12. (Cross-reference to tag A-0200).

Once inside of the day room, P11 returned to engage P12 in a confrontation that led to P11 physically assaulting P12. The surveyors observed no attempt by hospital staff, specifically the assigned to P11 one-to-one observer staff, to escort or remove P11 out of the day room, even after the hospital staff noticed that P11 re-entered the dayroom without permission.

During the physical assault, P11 was observed walking away from P12, then turning around to use an open hand to hit P12 in the back of his/her head. P12 stood from his/her seat and faced P11. P11 then used a closed fist to hit P12 three times in the face.

At the time of the above-described altercation between P11 and P12, two other patients were present in the day room: Patient #2 (P2) and Patient #4 (P4). Both P2 and P4 were on one-to-one (1:1) observation at the time. The surveyors noted that all facility staff who were present in the day room during the above-described altercation, except for one-to-one staff assigned to P11, exited the room, leaving P12, P2, and P4 alone with 1 staff member and an assaultive P11. The assigned one-to-one observers for P2 and P4 left their respective patients behind with a physically assaultive patient and did not attempt to remove these patients from the day room.

Based on review of 13 medical records, policies and procedures, interviews with staff, and video surveillance footage, the hospital staff failed to attempt/demonstrate effective intervention techniques prior to the initiation of restraint for 1 of 13 patients reviewed (Patient #11).

The findings include:

The surveyor reviewed the facility's policy titled, Seclusion and Restraint, last revised 10/18/2022, which stated in part, "Whenever possible, dangerous behaviors by patients are to be managed through non-physical, less restrictive interventions such as verbal de-escalation techniques, reassurance, offering the patient, a quiet place in which to regroup, such as a "Comfort Room" or "Quiet Room," as well as utilizing the patient's personal safety plan for preferred interventions."

Patient #11 (P11) was a minor patient admitted to the facility for treatment of behavioral health issues. On day 14 of P11's admission, a code green (behavioral health emergency which required additional assistance from the facility's security staff) was called for P11's physical assault of another minor patient (Patient #12).

Prior to the code green response, P11 was seen via video surveillance footage, displaying aggressive body language via hand gestures and posturing toward patient #12 (P12). The two patients were observed in the day room on the unit, sitting next to one another.

The facility's staff, including P11's 1:1 direct observer (a unit staff member assigned to always remain within a predetermined distance of a patient), was seen removing P11 out of the dayroom and closing the door; thus, prohibiting P11 from entering the day room to engage in further discourse with P12.

Outside of the day room, P11 was observed pacing the unit and looking through the day room door's window. Subsequently, P11 regained access to the day room after a staff member opened the door, allowing P11 entrance.

Once inside of the day room, P11 returned to engage P12 in a confrontation that led to P11 physically assaulting P12. (Cross-reference to tag A-0145)

The surveyors observed no attempt by hospital staff to deescalate P11 prior to the assault. There were no attempts to divert P11's attention to another activity or take P11 to another location after the staff noted that P11 was agitated from his/her interaction with P12.

In an interview with 2 Direct Care Assistants (DCA) on April 20 at 12:35 pm, the staff reported the charge nurse was told that P11 was exhibiting an escalation in behavior and required a code green intervention. Per the DCA staff, the charge nurse stated that the patient had to harm him/herself or others before a code green would be called.

Review of P11's medical record identified multiple code green events that lead to P11's placement into restraint. There was no personal safety plan noted in P11's treatment plan to prevent or mitigate the occurrence of these events.

Based on a review of 13 medical records, policies and procedures, interviews with staff, and video surveillance footage, the hospital nursing staff failed to provide clinical oversight of security staff who applied restraints to 2 of 13 patients reviewed (Patient # 1 and Patient #11).

The findings include:

The surveyors reviewed the policy titled, "Seclusion & Restraint", with a revision date of 10/18/2022. Under section IV. Seclusion/Restraint Orders, the policy stated, "F. The physician or RN must be present during the placement of the patient in seclusion/restraint and must observe the process."

1) Patient #1 (P1) was an adolescent patient who was admitted to this psychiatric hospital approximately eight months prior to the survey. P1 was admitted from an emergency department for mental health treatment.

During this inpatient stay, P1 was documented as having severe aggression towards staff and other patients almost daily. Restraint episodes were documented multiple times a week. On some days, more than one incident a day was documented. The documented behaviors prior to the restraint episodes included aggression, self-injurious behaviors and/or attempting to injure staff and other patients.

On 04/13/2023 at approximately 8:45 am, the surveyors reviewed video surveillance footage from a recent restraint episode which had occurred approximately 11 days prior to survey. The video showed 14 security officers responding to a Code Green (an emergency call for additional staff assistance). A member of the nursing staff was also seen in the doorway of P1's bedroom. A few minutes after the security officers arrived, one security guard was observed moving the nurse aside and entered P1's bedroom accompanied by five other security officers. Approximately 10 minutes later, the security officers brought P1 out of the room, carrying him/her face down and headfirst into the restraint room directly next door. Only security staff were seen entering the restraint room to apply restraints to P1. The nursing staff remained outside in the hallway, off to the side of the door. After several minutes, many of the officers were seen leaving the restraint room. At that time, a nurse was observed entering the restraint room.

On 4/13/2023 at approximately 09:30 am, the video of P1's restraint episode was reviewed in the presence of the director of security (DS). When the surveyors asked what security staffs' observed role was during restraint episodes, the DS stated that security staff generally "applies restraints on the patients. Once security staff has the patient restrained, the nurse enters to give the medication." No evidence was found to support that nursing staff assisted or provided clinical oversight during restraint episodes.

On 4/14/2023 at 10:40 am, an in-person interview was conducted with two members of the nursing staff who were observed on video surveillance during P1's restraint event. Both nurses stated that security staff would take direction from nursing staff during a restraint event. The nurses were asked if a direct observation of a restraint application could be achieved while standing in the hallway or at the bedside. Both nurses agreed that direct observation of the patient during the restraint application occurred at the bedside.

2) Patient #11 (P11) was an adolescent patient admitted to the facility approximately 12 days prior to the survey. P11 was admitted for treatment of behavioral health issues, including a history of violent and aggressive behaviors. The surveyors reviewed eight restraint episodes incurred by P11 during his/her hospital admission.

On 4/13/2023 at 2:30 pm, the surveyors reviewed real-time video surveillance footage of a restraint event for P11 resulting from a behavioral health emergency in which security staff was called to the unit to assist the nursing staff with restraining the patient, also known as a Code Green.

Based on the video surveillance footage, nursing staff was noted standing outside of the restraint room, while only security staff stayed inside of the room during the restraint application. At times, nursing staff did not have direct visualization of P11, while the security officers placed P11 into the restraints.

Based on a review of 13 medical records, polices, procedures and other pertinent documents and staff interviews, it was determined that the hospital failed to provide appropriate nursing staffing according to patient needs. This was evidenced by one staff member being assigned to care for a patient on an ordered one-to-one observation status while simultaneously monitoring another patient ordered for close observation.

The findings include:

The surveyors reviewed the policy, titled "Patients on Precautions" with a revision date of 01/22/2020. The following section stated, "1. Levels of Observations, B. Non-Routine: 1. Close (CO): maintained in addition to routine observation. The assignment of specific staff to visually monitor patients every 15 minutes with documentation every hour. 2. One to One: patient is assigned to a specific nursing staff to remain in proximity to the patient at all times with documentation on the Special Precautions/Observation Log every 15 minutes."

The surveyors also reviewed the policy titled, One-to-One Patient Supervision last revised 06/2022, which stated in part, "Constant nursing supervision will be provided to all patients on one-to-one supervision. This will promote the safety and welfare of the patient, facilitate prompt intervention for elopement/elopement attempt, maintain the therapeutic environment, and reduce serious destruction by a patient who is out of control ...The nursing staff member assigned to perform one-to-one supervision must be within arm ' s length at all times and accompany the patient to all activities and/or programs."

On 4/20/2023 at approximately 9:45 am, the surveyors reviewed Special Precautions/Observation Logs for five patients. On four of the five patients, it was noted that the same staff member documented on a close observation patient and a patient that was ordered for a one-to-one.

On 4/20/ 2023 at approximately 10:00 am, the surveyors interviewed nursing staff #3 (NS3) and direct care staff #7 (DCA7). The surveyors requested that the staff members explain the expectations and process for patients who are on close observation versus one-to-one supervision. DCA7 stated that patients on close observation were assigned a staff member who had the responsibility to observe the patients whereabouts every 15 minutes and document every hour. For patients on one-to-one, one staff member should be assigned to only one patient and should document the patient's behaviors and whereabouts every 15 minutes. NS3 agreed with this process.

Additionally, the surveyors reviewed the hospital's incident reports. The surveyors noted five documented occurrences over the previous two months related to patients who were ordered for one-to-one supervision. The incidents involved either patients that had a one-to-one order but did not have one-to-one staff coverage due to "lack of staffing" or a patient who was only on close observation when they were expected to have one-to-one coverage for safety.