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Based on interview, clinical record review, facility incident reports review, and facility policy review, it was determined the facility failed follow the policy and failed to ensure its patients were protected from patient-to-patient abuse as evidenced by one (1) patient (Patient #1) being physically abusive to four (4) of thirteen (13) sampled patients (Patients #4, #11, #12, and #13).

The findings include:

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety, Subsection 4 and Subsection 4.4," revised 01/07/12, revealed the facility defined physical abuse as any physical motion or action by which harm or injury occurred. This included hitting, slapping, pinching, punching, kicking or burning. This policy also revealed the facility sought to protect patients from all forms of abuse from any source.

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Patient Supervision," revised 01/07/12, revealed the level of supervision must provide the most appropriate and least restrictive care and treatment consistent with safety, welfare, and legal rights of patients, staff and the public; and the level of supervision shall be based on the ability of the patient to manage safely within a given level of supervision without unacceptable risk of serious harm to self or others. With all supervision levels, patients are observed with documentation every fifteen (15) minutes between 9:00 PM and 7:00 AM. This policy also defined different supervision levels as follows:

1. Support level: patient may leave the unit escorted by staff, and staff will observe the patient and document every thirty (30) minutes from 7:00 AM until 9:00 PM;

2. Support level-close observation: assigned staff must continually have patient in clear view and within twelve (12) feet;

3. Safety level: patient may not leave the unit, and staff will observe the patient and document every thirty (30) minutes from 7:00 AM until 9:00 PM;

4. Safety level-fifteen (15) minute checks: patient is at low risk for injury, but identified risk factors are present, and staff will observe the patient and document every fifteen (15) minutes;

5. Safety level-close observation: patient is at moderate risk for injury, and assigned staff must continually have patient in clear view and within twelve (12) feet;

6. Safety level-one to one observation: patient is at high risk for injury, and assigned staff must continually have patient in clear view and be within a leg's length of the patient.

Review of the clinical record of Patient #1 revealed he/she was admitted under a court order on 01/21/12 with Diagnoses including Psychosis Not Otherwise Specified (NOS). Prior to admission he/she had exhibited violent outbursts at a Personal Care Home where he/she resided. Patient #1's admission supervision was safety level-fifteen (15) minute checks. The record further revealed the level was changed to support on 03/26/12 where it remained until 04/20/12, when it was changed back to safety level-fifteen (15) minute checks. Further review of the clinical record of Patient #1, in addition to facility incident reports, revealed there were nine (9) incidents of physical abuse by this patient to four (4) other patients and staff between 04/13/12 and 04/22/12. On 04/23/12, when a bed became available, Patient #1 was moved to the Intensive Service Unit (ISU), a four (4) bed unit where there was more patient supervision by staff. The nine (9) incidents are as follows:

1. On 04/13/12 at 4:50 PM, Patient #1 knocked Patient #4 out of a chair and then started kicking him/her in the abdominal area, unprovoked; Patient #1 received Benadryl 50 milligrams (mg) by mouth to decrease agitation and went to his/her room for a time-out; there was no change in level of supervision.

2. On 04/13/12 at 6:15 PM, Patient #1 was agitated due to restricted privileges for attacking a peer earlier in the day; he/she picked up a chair near the Nurses' Station and threw it at the staff; he/she then went into the Nurses' Station and attempted to grab the vital sign machine; Patient #1 was placed into restraints and Zyprexa 10 mg intramuscular (IM) was given to calm patient; there was no change in level of supervision.

3. On 04/14/12 at 3:30 PM, Patient #1 put Patient #11 in a headlock and began punching him/her after Patient #11 yelled in Patient #1's face. Patient #1 was given Zyprexa 10 mg IM to calm patient; there was no change in level of supervision.

4. On 04/16/12 at 11:45 AM, Patient #1 was agitated due to Patient #11 screaming in his/her face; Patient #1 attempted to attack Patient #11; when staff tried to redirect Patient #1, he/she attempted to hit and kick staff; Patient #1 was placed in restraints and received Haldol 5 mg by mouth, Benadryl 50 mg by mouth and Ativan 2 mg by mouth to calm patient; there was no change in level of supervision.

5. On 04/18/12 at 7:40 PM, Patient #1 began verbally arguing with Patient #4 and then began physically fighting with Patient #4. Patient #1 received IM injections of Haldol 5mg, Benadryl 50 mg and Ativan 2 mg at 7:50 PM to calm him/her; there was no change in level of supervision; however; on 04/20/12, after a consensual sexual incident between Patient #1 and Patient #2, the level of supervision was changed to safety-fifteen (15) minute checks.

6. On 04/21/12 at 12:20 PM, Patient #1's forearm was grabbed by Patient #12. Patient #1 began striking Patient #12 about the face and right ear. Patient #1 received IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg at 12:45 PM to calm him/her; there was no change in level of supervision.

7. On 04/21/12 at 5:20 PM, Patient #1 and Patient #11 were standing at the Nurses' Station; unprovoked, Patient #1 attacked Patient #11 by punching him/her in the right side of the face. Patient #1 was placed in restraints and given IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg at 5:30 PM to calm him/her and also due to aggressive behavior with staff; there was no change in level of supervision.

8. On 04/22/12 at 12:40 PM, Patient #1 attacked Patient #13 by punching him/her in the head. Patient #1 also attacked a staff member. Patient #1 was given IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg to calm him/her and was taken to the time-out room; there was no change in level of supervision.

9. On 04/22/12 at 2:50 PM, Patient #1's arm was grabbed by Patient #12. Patient #1 began slapping Patient #12. Patient #1 received IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg to calm him/her and was taken to the time-out room; there was no change in level of supervision.

Review of the clinical record of Patient #4 revealed he/she was admitted on 02/20/01 with Diagnoses including Schizoaffective Disorder, Bipolar Type. The incidents with Patient #1 were documented in this record, and Patient #4's supervision level was support.

Review of the clinical record of Patient #11 revealed he/she was admitted on 04/09/12 and discharged on 04/23/12 to supported community living (SCL). Diagnoses included Schizoaffective Disorder, Asperger Disorder, Seizure Disorder, and Mild Mental Retardation. The incidents with Patient #1 were documented in this record. Patient #11's supervision level for the incidents on 04/14/12 and 04/16/12 was support, and for the incident on 04/21/12, safety.

Review of the clinical record of Patient #12 revealed he/she was admitted on 04/20/12 with assault precautions due to violent behavior at home. Diagnoses included Severe to Profound Mental Retardation. Patient #12 was placed on safety level with one to one observation due to his/her severe mental and physical limitations. The incidents with Patient #1 were documented in this record.

Review of the clinical record of Patient #13 revealed he/she was admitted on 04/20/12 with Diagnoses which included Depressive Disorder with Suicidal Ideation, Diabetes, and Substance Abuse. Initial level of supervision was safety with close observation until 04/23/12 when it was changed to support. Patient #13 was discharged on 04/27/12 to home. The incident with Patient #1 was documented in this record. Per Progress Notes, written on 04/23/12 at 4:00 PM, Patient #13 was sent to the emergency room for a CT scan (results were negative) following this incident.

Interview with Patient #1, on 04/27/12 at 2:15 PM, revealed he/she had been in two (2) physical fights since being in the facility. Patient #1 stated he/she punched a patient that had grabbed him/her from behind, and when a staff member separated them, he/she punched that staff member. Patient #1 revealed this incident constituted two (2) fights and these were the only physical altercations he/she had experienced.

Interview with Patient #11, on 04/30/12 at 6:00 PM, revealed he/she could not remember the name of the patient but did remember the patient hit him/her in the head four (4) times. Patient #11 further revealed that he/she only remembered one (1) incident, and when it occurred, the patient just came up and starting hitting him/her in the head.

Interview with Registered Nurse (RN) #1, on 04/27/12 at 4:40 PM, revealed Patient #1's behavior had escalated during the approximate two (2) week period before he/she went to the ISU on 04/23/12. RN #1 further revealed she believed Patient #1 needed to go to the ISU sooner than he/she did. She also stated Patient #1's behavior was very unpredictable.

Interview with RN #2, on 04/30/12 at 3:33 PM, revealed Patient #1 had injured her arm and neck during the 04/22/12 12:40 PM incident. She went to the emergency room and a CT of the neck and x-rays of the left arm and upper back were performed. She further revealed that findings from the emergency room visit were a contusion of the left elbow and a sprain/strain of the neck. RN #2 stated at the time she left the floor, on 04/22/12 at 2:30 PM, Patient #1 was standing at the Nurses' Station, and because of this, she was hesitant to walk out the door which was close to where Patient #1 was standing.

Interview with Mental Health Associate (MHA) #1, on 05/01/12 at 3:00 PM, by telephone, revealed she had observed the incident on 04/14/12 with Patient #11 and the incident either on 04/21/12 or 04/22/12 with Patient #12. She further revealed when Patient #1 "goes off, nobody is safe. Saying the wrong word, or looking at him/her might make him/her go off."

Interview with MHA #2, on 05/01/12 at 4:11 PM, by telephone, revealed he had been involved in the four (4) incidents occurring on the weekend of 04/21/12 to 04/22/12. He further revealed that because of Patient #1's behavior, he was always attentive to where he/she was located. Also, he revealed he was nervous about Patient #1 being around the other patients on the floor, especially Patient #12.

Interview with Risk Manager #1, on 04/30/12 at 1:20 PM, revealed when any patient had more than one altercation the process would be for the facility to see what changes could be made in the treatment plan to prevent further problems.

Interview with the Attending Physician for Patient #1, on 05/02/12 at 4:05 PM, revealed Patient #1 did not have predictable behavior. He stated Patient #1 had Intermittent Explosive Disorder which caused his/her behavior to escalate rapidly. Lastly, he revealed Patient #1 had an Intelligence Quotient (IQ) of 58 which was in the mild mental retardation range which made his/her case more complex.

Based on interview, clinical record review, facility incident reports review, and facility policy review, it was determined the facility failed follow the policy and failed to ensure its patients were protected from patient-to-patient abuse as evidenced by one (1) patient (Patient #1) being physically abusive to four (4) of thirteen (13) sampled patients (Patients #4, #11, #12, and #13).

The findings include:

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety, Subsection 4 and Subsection 4.4," revised 01/07/12, revealed the facility defined physical abuse as any physical motion or action by which harm or injury occurred. This included hitting, slapping, pinching, punching, kicking or burning. This policy also revealed the facility sought to protect patients from all forms of abuse from any source.

Review of the facility's policy, "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Patient Supervision," revised 01/07/12, revealed the level of supervision must provide the most appropriate and least restrictive care and treatment consistent with safety, welfare, and legal rights of patients, staff and the public; and the level of supervision shall be based on the ability of the patient to manage safely within a given level of supervision without unacceptable risk of serious harm to self or others. With all supervision levels, patients are observed with documentation every fifteen (15) minutes between 9:00 PM and 7:00 AM. This policy also defined different supervision levels as follows:

1. Support level: patient may leave the unit escorted by staff, and staff will observe the patient and document every thirty (30) minutes from 7:00 AM until 9:00 PM;

2. Support level-close observation: assigned staff must continually have patient in clear view and within twelve (12) feet;

3. Safety level: patient may not leave the unit, and staff will observe the patient and document every thirty (30) minutes from 7:00 AM until 9:00 PM;

4. Safety level-fifteen (15) minute checks: patient is at low risk for injury, but identified risk factors are present, and staff will observe the patient and document every fifteen (15) minutes;

5. Safety level-close observation: patient is at moderate risk for injury, and assigned staff must continually have patient in clear view and within twelve (12) feet;

6. Safety level-one to one observation: patient is at high risk for injury, and assigned staff must continually have patient in clear view and be within a leg's length of the patient.

Review of the clinical record of Patient #1 revealed he/she was admitted under a court order on 01/21/12 with Diagnoses including Psychosis Not Otherwise Specified (NOS). Prior to admission he/she had exhibited violent outbursts at a Personal Care Home where he/she resided. Patient #1's admission supervision was safety level-fifteen (15) minute checks. The record further revealed the level was changed to support on 03/26/12 where it remained until 04/20/12, when it was changed back to safety level-fifteen (15) minute checks. Further review of the clinical record of Patient #1, in addition to facility incident reports, revealed there were nine (9) incidents of physical abuse by this patient to four (4) other patients and staff between 04/13/12 and 04/22/12. On 04/23/12, when a bed became available, Patient #1 was moved to the Intensive Service Unit (ISU), a four (4) bed unit where there was more patient supervision by staff. The nine (9) incidents are as follows:

1. On 04/13/12 at 4:50 PM, Patient #1 knocked Patient #4 out of a chair and then started kicking him/her in the abdominal area, unprovoked; Patient #1 received Benadryl 50 milligrams (mg) by mouth to decrease agitation and went to his/her room for a time-out; there was no change in level of supervision.

2. On 04/13/12 at 6:15 PM, Patient #1 was agitated due to restricted privileges for attacking a peer earlier in the day; he/she picked up a chair near the Nurses' Station and threw it at the staff; he/she then went into the Nurses' Station and attempted to grab the vital sign machine; Patient #1 was placed into restraints and Zyprexa 10 mg intramuscular (IM) was given to calm patient; there was no change in level of supervision.

3. On 04/14/12 at 3:30 PM, Patient #1 put Patient #11 in a headlock and began punching him/her after Patient #11 yelled in Patient #1's face. Patient #1 was given Zyprexa 10 mg IM to calm patient; there was no change in level of supervision.

4. On 04/16/12 at 11:45 AM, Patient #1 was agitated due to Patient #11 screaming in his/her face; Patient #1 attempted to attack Patient #11; when staff tried to redirect Patient #1, he/she attempted to hit and kick staff; Patient #1 was placed in restraints and received Haldol 5 mg by mouth, Benadryl 50 mg by mouth and Ativan 2 mg by mouth to calm patient; there was no change in level of supervision.

5. On 04/18/12 at 7:40 PM, Patient #1 began verbally arguing with Patient #4 and then began physically fighting with Patient #4. Patient #1 received IM injections of Haldol 5mg, Benadryl 50 mg and Ativan 2 mg at 7:50 PM to calm him/her; there was no change in level of supervision; however; on 04/20/12, after a consensual sexual incident between Patient #1 and Patient #2, the level of supervision was changed to safety-fifteen (15) minute checks.

6. On 04/21/12 at 12:20 PM, Patient #1's forearm was grabbed by Patient #12. Patient #1 began striking Patient #12 about the face and right ear. Patient #1 received IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg at 12:45 PM to calm him/her; there was no change in level of supervision.

7. On 04/21/12 at 5:20 PM, Patient #1 and Patient #11 were standing at the Nurses' Station; unprovoked, Patient #1 attacked Patient #11 by punching him/her in the right side of the face. Patient #1 was placed in restraints and given IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg at 5:30 PM to calm him/her and also due to aggressive behavior with staff; there was no change in level of supervision.

8. On 04/22/12 at 12:40 PM, Patient #1 attacked Patient #13 by punching him/her in the head. Patient #1 also attacked a staff member. Patient #1 was given IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg to calm him/her and was taken to the time-out room; there was no change in level of supervision.

9. On 04/22/12 at 2:50 PM, Patient #1's arm was grabbed by Patient #12. Patient #1 began slapping Patient #12. Patient #1 received IM injections of Haldol 5 mg, Benadryl 50 mg, and Ativan 2 mg to calm him/her and was taken to the time-out room; there was no change in level of supervision.

Review of the clinical record of Patient #4 revealed he/she was admitted on 02/20/01 with Diagnoses including Schizoaffective Disorder, Bipolar Type. The incidents with Patient #1 were documented in this record, and Patient #4's supervision level was support.

Review of the clinical record of Patient #11 revealed he/she was admitted on 04/09/12 and discharged on 04/23/12 to supported community living (SCL). Diagnoses included Schizoaffective Disorder, Asperger Disorder, Seizure Disorder, and Mild Mental Retardation. The incidents with Patient #1 were documented in this record. Patient #11's supervision level for the incidents on 04/14/12 and 04/16/12 was support, and for the incident on 04/21/12, safety.

Review of the clinical record of Patient #12 revealed he/she was admitted on 04/20/12 with assault precautions due to violent behavior at home. Diagnoses included Severe to Profound Mental Retardation. Patient #12 was placed on safety level with one to one observation due to his/her severe mental and physical limitations. The incidents with Patient #1 were documented in this record.

Review of the clinical record of Patient #13 revealed he/she was admitted on 04/20/12 with Diagnoses which included Depressive Disorder with Suicidal Ideation, Diabetes, and Substance Abuse. Initial level of supervision was safety with close observation until 04/23/12 when it was changed to support. Patient #13 was discharged on 0