HospitalInspections.org

Based on an unannounced onsite visit, video recording review, hospital policies, hospital forms, medical record review and interviews, the Governing Body failed to be effective in carrying out its responsibilities and oversight for the conduct of the hospital and to ensure the hospital's ongoing compliance with all Conditions of Participation that would ensure the safety and quality of care to be provided to all patients.

The findings included:

1. On 2/11/2019 the hospital's Governing Body was cited for failure to ensure all Patient Rights were promoted, patients were protected and all patients received care in a a safe setting. The Governing Body failed to ensure the needs of each patient were identified and a plan of care was developed and implemented to ensure each patient received the appropriate care and services. Video recordings viewed during the survey revealed Patients were being physically and emotionally abused by staff. The hospital was cited an Immediate Jeopardy and was put back into substantial compliance on 6/25/2019.
Refer to survey dated 2/11/2019 - 6/25/2019.

2. On 5/28/2020 the hospital was cited for failure to ensure all Patient Rights were promoted and ensure the hospital had a system in place to develop and implement Behavior Management Plans, failed to update patient's individual treatment plans, and failed to ensure all patients were free from abuse. Patients were attacking vulnerable patients as well as staff members. The hospital was cited an Immediate Jeopardy and an acceptable Removal Plan was submitted by the hospital.

On 6/17/2020 an onsite visit was conducted and the hospital's Governing Body was cited for failure to ensure the implementation of the hospital's Removal Plan to protect all patients from abuse. A patient was displaying sexually aggressive behaviors to vulnerable patients. There were no Observation Precautions documented on the sexually aggressive acting patient. Another patient was aggressively disrupted and tearing objects. There was lack of documentation the patient had received the prescribed medications for anger and aggression. Elopement precautions were not documented as ordered for a patient with eloping seeking behaviors. There was no documentation the Governing Body had guided and managed the care and treatments provided by the hospital or identified issues of quality and safety and implemented procedures to address processes or system issues.

On 7/15/2020 the hospital's Governing Body was re-cited at a Condition level to allow the hospital the opportunity to ensure its plan of correction could be effective and be sustained ongoing.

On 10/1/2020 the hospital was placed back into substantial compliance withe the Conditions of Participation.
Refer to surveys 5/28/2020 - 10/1/2020.

3. During the current survey, the hospital's Governing Body has failed to to be effective in carrying out its responsibilities and assure that the hospital services were provided in compliance with the Conditions of Participation. The Governing Body failed to identify quality and performance problems with the nursing services and implement corrective actions in order to ensure patients received care in a safe setting and remained free from any form of abuse. The Governing Body failed to ensure previous action plans in relation to abuse and patient care were effective, ongoing, sustained and were revisited in order to identify any issues and effective interventions had been implemented to prevent abuse from re-occurring.
Refer to A115, A144, A145, A385 and A386.

Based on facility policy review, facility document review, medical record review, video recording review, and interview, the facility failed to ensure patients' rights were protected to receive care in a safe setting and failed to ensure all patients' were free of abuse for 1 of 1 (Patient #1) who was abused and for 1 of 1 (Patient #6) who staff neglected to ensure the patient's safety from fire hazards.

The findings included:

1. Review of the "ALLEGED PATIENT ABUSE, NEGLECT, AND EXPLOITATION" policy dated "10/2020" revealed, "... the patient has the right to be free from all forms of abuse ... All employees are required to adhere to this policy ... To protect the patient immediately when abuse or neglect is witnessed or reported ... To ensure patients are treated with dignity and respect in accordance with the Patient's Rights ... To ensure that incidents or allegations concerning patient abuse and/or neglect are handled fairly, thoroughly, and expeditiously ... "

Review of the "SPECIAL PRECAUTIONS" policy dated "10/2020" revealed, "... Assault Precautions ... Staff members trained in management of assaultive behavior and de-escalation techniques will complete thorough and ongoing assessments for potential of assault; implement appropriate treatment at the onset of increased patient agitation; prevent or minimize injuries if patient attempts to physically assault patients, staff, or visitors ... "

Medical record review revealed Patient #1, a 29-year-old Caucasian male, was involuntarily admitted to the facility on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar, and Seizure Disorder. Patient #1 was placed on every 15 minute observations for Assault and Seizure precautions.

Record review, facility video review and interview revealed during the night medication pass on 9/8/2021 beginning at 8:41 PM, Patient #1 was handed his night medications by Registered Nurse (RN) #1 and the patient immediately disposed of his medications in the garbage can. RN #1 walked from behind the nurse's counter, pointed her finger at the patient's face and confronted Patient #1's refusal to take the medications. RN #1 told Patient #1, patients that don't take their medications, can't go out to smoke. A physical fight ensued between Patient #1 and RN #1. Patients # 2, #3, #4, #5 and #6 were waiting in line behind Patient #1 and these patients proceeded to intervene and hit Patient #1. Other staff members attempted to break the fight up and the other staff members were observed holding Patient #1 on the floor. RN #1 was then observed punching Patient #1 in the head while the patient was being held down on the floor. Patient #1 appeared to be bleeding and experiencing a seizure after the attack by RN #1. RN #1 was finally subdued by other staff and the fight was broken up. Patient #1 was dragged into a closed office by another staff member when the video ended.

After the fight, Patient #1 was taken to the front lobby waiting room and left alone. During the time Patient #1 was left alone, he eloped from the facility grounds. Patient #1 was later found at the bypass intersection and brought back to the facility by the city police. Patient #1 was eventually sent to another acute care hospital's emergency department (ED) and returned later to the hospital in stable condition. RN #1 immediately resigned after the incident.

The facility failed to ensure Patient #1 was free of abuse neglect.

Refer to A0145

2. Review of the facility's "SAFETY SEARCHES" policy dated "3/2020" revealed, " Delta Specialty Hospital strives to maintain a safe and therapeutic environment for patients, visitors and staff. In order to achieve this, routine searches should be conducted on all patients on admission ... Other searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient may possess and item which is potentially hazardous. When patient safety is a factor, the Nursing Supervisor may authorize a search and then contact the physician, for those searches requiring a physician order ... "

Review of the facility's "CONTRABAND" policy dated "11/2020" revealed, " ... Delta Specialty Hospital is committed to a safe environment free of contraband; drugs, weapons, alcohol and other items deemed a safety risk or hazard. ... Staff will consider the following to be contraband ... Cigarette lighters or matches ..."

Review of the facility's "Smoking: Privileges for Behavioral Health Patients" policy dated "11/2017" revealed, "...This is a non-smoking facility with the exception of Behavioral Health Patients. Patients receiving psychiatric and/or chemical dependency may have significant difficulty if this substance is withheld ... Smoking will be allowed only in designated outside smoking area in the courtyard ... Behavioral Health patients will have restricted smoking areas but employees will not be allowed to smoke in the Behavioral Health areas..."

Medical record review revealed Patient #6 was a 33 year old African American male who was admitted to the hospital on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

On 9/6/2021 staff smelled cigarette smoke and found ashes in Patient #6's room. Staff were unable to find the source and the patient refused a search, other than a pat down. There was no evidence safety checks or observations were increased, or other interventions put into place after the staff had smelled the cigarette smoke and cigarette ashes.

On 9/7/2021 Patient #6 was smoking in his room and caught his bed on fire. The fire alarms sounded and the patients were evacuated. The fire was extinguished by the sprinklers before the fire department arrived.

The facility failed to implement effective interventions to protect patients and to ensure the safety of all the patients.

Refer to A144

Based on facility policy, medical record review, and interview, the facility failed to provide appropriate observations, monitoring and interventions to ensure all patients received care in a safe setting for 1 of 1 (Patient #6) sampled patients who was smoking in their rooms and caught their bed on fire.

The findings included:

1. Review of the facility's "SAFETY SEARCHES" policy dated "3/2020" revealed, "Delta Specialty Hospital strives to maintain a safe and therapeutic environment for patients, visitors and staff. In order to achieve this, routine searches should be conducted on all patients on admission ... Other searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient may possess and item which is potentially hazardous. When patient safety is a factor, the Nursing Supervisor may authorize a search and then contact the physician, for those searches requiring a physician order ... Patient Search ... After admission, whenever there is reasonable cause to believe the patient may possess a potentially dangerous item, he/she may be searched at that time, with notification to the physician ...
An invasive body search may be ordered by the physician for a patient if there is reasonable cause to believe that the patient has hidden contraband in a body orifice. The patient will be placed on a 1 to 1 observation and transferred to a medical facility ...
During the patient search, remove any contraband and handle as per facility's policy on contraband disposition; report search findings to the attending physician as indicated ...
If the patient objects to the search, explain the facility's policy to the patient, stating that the search is required to maintain safety for everyone and is required prior to continued treatment at the facility ...
If the patient continues to refuse the search, the physician should be notified and one of the following may occur: If the patient is voluntary and determined not to be dangerous to himself/herself or others; he/she may be discharged AMA (Against Medical Advice)...
Room Search ... Environmental rounds are conducted daily by unit staff once per shift... If contraband is suspected on the patient unit, it may be preferable to conduct a unit-wide room search ..."

2. Review of the facility's "CONTRABAND" policy dated "11/2020" revealed, "...Delta Specialty Hospital is committed to a safe environment free of contraband; drugs, weapons, alcohol and other items deemed a safety risk or hazard. ... Staff will consider the following to be contraband ... Items to be secured in a designated area (e.g. property room), hospital security, or restricted from being brought in by visitors ... Cigarette lighters or matches ..."

3. Review of the facility's "Smoking: Privileges for Behavioral Health Patients" policy dated "11/2017" revealed, "...This is a non-smoking facility with the exception of Behavioral Health Patients. Patients receiving psychiatric and/or chemical dependency may have significant difficulty if this substance is withheld ... Smoking will be allowed only in designated outside smoking area in the courtyard ... Behavioral Health patients will have restricted smoking areas but employees will not be allowed to smoke in the Behavioral Health areas..."

4. Medical record review revealed Patient #6, was a 33 year old male who was admitted to the facility on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

Review of the 9/6/2021 Nursing Note at 8:00 PM revealed, "Heavy smell of cigaaretter [cigarette] smoke in patient's room. Cigarette ashes found around patient's bed in his garbage in his toilet bowl and around toilet bowl. Patient also had a ball point pen on his person that he refused to relinquish. His belongings were searched by this RN [registered nurse] and [name of Behavioral Health Technician (BHT) #3] but unable to find smoking paraphernalia. Notified Nursing Supervisor and called support team. Lead Tech went in room with patient at which time he denied ever having the ball point pen and smoking material. He was taken from room and patted down but strip search was not done. No contraband was found". There was no evidence a unit-wide room search was completed, an invasive search completed, education about the hospital's policy completed, 1:1 observations implemented or other safety interventions completed to determine where the contraband may be hidden.

Review of the Nursing Note dated 9/7/2021 revealed, "00:10 [12:10 AM] Fire alarm going off. Smoke in hallway went to [Patient #6]room and found bed ablaze and patient standing in the room in front of the window refusing to be evacuated from the room and somoke [smoke] thick in the room."

Review of the Nursing Note dated 9/7/2021 revealed, " 00:15 [12:15 AM] After evacuating remainder of the patients returned to the room to evacuate the patient and he refused and became threatening Fire department has been called. Patient came out of the room smoking a cigarette. He picked up the COW [computer on wheels] and began slamming it on the floor and breaking it apart. He slammed it against the wall and attempted to slam it against the window. [Name of physician] was notified and orders obtained to medicate patient with haldol 5 mg [milligram] and ativan 2mg IM [intramuscular]. Transfer to ITU [intensive treatment unit] and place him on 1:1 observation. Patient was medicated and transferred."

Review of the Nurse Shift Reassessment note dated 9/8/2021 at 5:05 PM revealed, "... When asked why he [Patient #6] started the fire he said because, 'I was mad and upset'... Intervention q [every] 15 min checks ..."

In an interview on 9/29/2021 at 1:00 PM the Chief Operating Officer (COO) stated that on 9/6/2021 Patient #6 had been smoking in his room and there was evidence of ashes in the patient's toilet bowl, around the patient's toilet and in the patient's garbage can in the bathroom. The COO stated, "The support team was called to the unit, they did a pat down and didn't find anything. The patient refused a full search ... except for a pat down, while he was still wearing his clothes." The COO stated, "could not identify where he had the cigarettes and lighter..." He [Patient #6] did later say he hid the lighter in his rectum..."

The COO stated the incident of Patient #6's bed on fire occurred on 9/7/2021 around 12:10 AM. The COO stated the fire alarm sounded, the tech went to the patient's room and smoke was coming out of the patient's room. Patient #6 "refused" to leave the room. The other patients were evacuated by staff. [name of Patient #6] became more destructive of property in the room. Fire Department arrived in the lobby at 12:24 AM and on the unit at 12:29 AM. The fire had already been extinguished by the [hospital's] sprinklers..."

When asked if Patient #6's observation precautions were increased or other interventions implemented after evidence was found that Patient #6 was smoking in his room on 9/6/2021 and the COO stated there was no documentation the physician was notified of the 9/6/2021 incident and no documentation the patient's observation/monitoring was increased.

Based on hospital policy, hospital forms, the hospital's video recording, medical record review and interview, the hospital failed to ensure all patients were free from abuse, failed to protect all patients from injuries, and failed to immediately identify abuse and implement behavior interventions to prevent abuse from occurring for 1 of 1 (Patient #1) sampled patients who was abused by hospital staff and other patients, and for 5 of 5 (Patients #2, #3, #4, #5 and #6) patients who participated in fighting and exhibiting aggressive behaviors and new interventions were not developed or implemented for those behaviors.

The findings included:

1. Review of the facility's "ALLEGED PATIENT ABUSE, NEGLECT, AND EXPLOITATION" policy dated "10/2020" revealed, "... Delta Specialty Hospital believes the patient has the right to be free from all forms of abuse ... All employees are required to adhere to this policy ...
PURPOSE ...To protect the patient immediately when abuse or neglect is witnessed or reported ... To ensure patients are treated with dignity and respect in accordance with the Patient's Rights ... To ensure that incidents or allegations concerning patient abuse and/or neglect are handled fairly, thoroughly, and expeditiously ...
Definitions ... Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish (CMS State Operations Manual, 2020). Abuse may be physical, sexual, verbal, or exploitive...
Neglect is considered a form of abuse and defined as the failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness (CMS State Operations Manual, 2020) ...
Serious Bodily Injury: Bodily injury, which creates a substantial risk of death or which causes serious permanent disfigurement or protracted loss or impairment if function of any bodily member organ ...
Serious Mental Injury: Psychological condition, as diagnosed by a physician or licensed psychologist, which renders a patient chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic, or in reasonable fear that his/her life or safety is threatened ...
Serious physical injury: an injury that causes a patient severe pain, significantly impairs or partially impairs physical functioning, either temporarily or permanently ...
Protocol: Alleged Abuse or Neglect Occurring Within the Hospital Setting ... An employee who observes or receives notification from a patient or visitor any actions defined as abuse and/or neglect will immediately report it to the Charge Nurse ...
The Charge Nurse will intervene to ensure patient safety by separating the patient from the staff ...
The Charge Nurse will notify the House Supervisor of the allegation ...
The House Supervisor will report to the unit to initiate the investigation of the allegation. The House Supervisor will escort the staff to the Human Resources Office, if during business hours. If outside of normal HR [Human Resources] hours, the House Supervisor will escort to the nursing administration office, away from patient care areas ...
The House Supervisor will notify the Risk Manager, HRD [Human Resource Director], and CEO of the allegation. a. The staff will be placed on administrative leave pending the outcome of the investigation. The HRD or House Supervisor will obtain the staff's badge and keys and escort the staff out of the hospital ...
The patient is to be interviewed by the Chief Nursing Officer, Director of Clinical Services or Risk Manager and assessed for injuries by the Charge Nurse or CNO. This assessment will be documented in a progress note ..."

Review of the facility's "SPECIAL PRECAUTIONS" policy dated "10/2020" revealed, "... Assault Precautions ... Staff members trained in management of assaultive behavior and de-escalation techniques will complete thorough and ongoing assessments for potential of assault; implement appropriate treatment at the onset of increased patient agitation; prevent or minimize injuries if patient attempts to physically assault patients, staff, or visitors ... Upon admission, all patients will be evaluated for level of assault potential ... Risk factors for assault may include ... Previous history of violence ... Frequent arguments with others ... Command hallucinations ... Persecutory delusions ... Impulsivity ... Male gender ... Young adulthood ... Lower intellectual functioning ...
...Any changes in behavior or events which may increase potential for assaultive behavior (i.e. arguments with other patients or visitors, sexually acting out by inappropriate touching or sexual comments, hallucinations, increased paranoia, or guarded behavior, increased motor activity, ect.) ... Staff interventions for the assaultive/aggressive patient may include ... Utilization of verbal de-escalation skills ... Healthy distractions ... Use a calm conversational tone when speaking with patients ... Provide reasonable alternatives ... Offer quiet time ... Prompt the patient for their individualized relaxation skill ... Avoid the patient's identified triggers ... Use of CPI [Crisis Prevention Institute Non-Violent Intervention] techniques ... Use of PRN [as needed] medications to decrease agitation ... "

2. Medical record review revealed Patient #1 was a 29-year-old Caucasian male was involuntarily admitted to the hospital on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar, and Seizure Disorder.

Review of the 9/4/2021 Intake Assessment revealed Patient #1 had a history of multiple psychiatric hospital admissions. The patient presented to the hospital with homicidal ideations towards his family, threatening to cut their heads off with a box cutter and burn down the house, and speaks to demons. The patient believed his father wanted to melt him with Hydrochloric Acid.

The High Risk Notification form revealed Patient #1 was put on every 15 minute observations for Assault and Seizure precautions.

Review of the 9/8/2021 Nurse Shift Reassessment note for 4:02 PM revealed, " ... Behavior... calm and cooperative today... compliant with treatment ... He is able to be redirected ... remains somewhat withdrawn, possible responding to internal stimuli, but answers questions in a timely manner with appropriateness."

3. Review of hospital form revealed an fighting incident occurred on 9/8/2021 at approximately 8:41 PM after Patient #1 refused their 9:00 PM medications. There was no documentation the physician was notified of the patient's refusal of their medications. The hospital form revealed the Registered Nurse (RN) #1 confronted the patient and a fight ensued.

A late entry nurse progress note dated 9/9/2021 at 1:42 AM documented that on 9/8/2021 at 8:41 PM, "...Pt [Patient #1] has been labile, aggressive, combative, escalates peers by using the 'N' word around a group of black peers. Pt demonstrates poor judgement by continuing to spit on staff resulting in patient being hit and punched more... Pt placed on 1:1 and moved to the front area [lobby] where the patient eloped from of the hospital, was picked up by the police and returned to the hospital. Pt housed on DDU [Dual Diagnosis Unit] on 1:1 until orders to transfer to medical ED [emergency department] for evaluation and treatment...obtained and pt is picked up at [Name of acute care Hospital #2] ... Pt initially stated he was going to refuse all treatment however is compliant when told he has an involuntary status and he would be evaluated. Plan: Continue 1:1 status... Skin: Bruised ..."

On 9/8/2021 at 12:15 PM the House Supervisor documented a late entry note which stated, "At 2021 [On 9/8/2021 at 8:21 PM- but actually began at 8:41 PM], pt [Patient #1] was reported to have been given his HS [night time] medications and throwing them in the trash can. Pt was reported to have been confronted by the medication nurse [RN #1] and pt is reported to have punched the nurse in the face. It is reported that the patient's peers jumped on him and began to beat him. Writer observed patient [Patient #1] after he had been moved to the small nursing station which is locked and his peers could not reach him. Pt is shaking, appears to be in pain and has blood covering his face. Pt remained in this area until all patients could be put in their rooms. It was reported patient had a short period of what may have been seizure activity. Writer directed that the patient was to be moved to the DDU [Dual Diagnosis Unit] unit until he could be transferred to a medical facility to be examined and treated as needed. The patient was placed in the front lobby with a nurse and the security guard". The House Supervisor documented the nurse and security guard left Patient #1 unattended in the hospital's lobby and when the security guard went looking for Patient #1 the hospital lobby doors to the outside were seen opened.
The House Supervisor documented, "[Patient #1] had eloped. Security called the police who stopped and detained the patient near the 240 entrance [the local highway approximately one (1) and one half ( 1/2) miles down the road from the hospital]. Police called the EMT [Emergency Medical Tech] to see patient, cleared the patient and the police returned the patient to the hospital. The patient was moved to the DDU unit until orders and transportation arrives for transfer to a medical facility to be examined. Pt placed on a 1:1. Pt was to go to [Name of Hospital #3] but was inadvertently transferred to [Name of Hospital #2] where he remained throughout the night. Pt's emergency contact notified of patient's status and need for transfer to medical for evaluation. The nurse manager and CNO [Chief Nursing Officer] notified of the above."

Review of the Emergency Department (ED) report from Hospital #2 for Patient #1 revealed the patient arrived at the ED on 9/9/2021 at 12:53 AM. The ED physician documented the patient was seen immediately on arrival. The ED physician documented the patient presented for "... assault- punched in the face, short seizure after assault... possible LOC [loss of consciousness] ... stated that he was assaulted ...because he refused to take medication ...stated he was beaten pretty badly... the patient became tearful while obtaining H&P [history and physical], stated he was raped all his life..." The ED physician documented the patient had a small abrasion to his right elbow, few abrasions on his face, bilateral periorbital small ecchymosis, right elbow tenderness with mild swelling and small ecchymosis. The patient was discharged back to the hospital after being medically cleared.

4. Review of the nurse progress note dated 9/9/2021 at 1:30 PM revealed RN #5 documented, "Pt [Patient #1] arrived back on unit from [Name of Hospital #2] ER. Pt has significant bruising to face and extremities, and C/O [complained of] generalized body pain rated as 10/10 on Pain scale. [Name of physician and nurse practitioner] notified of pt's return. Toradol 30 mg IM [Intramuscular] now ordered and administered as ordered..."

5. Review of a written statement dated 9/28/2021 at 6:00 AM, RN #3 documented, "Late entry for 9/8/21 @ 2100 [at 9:00 PM] ...I was charting in the nurse's station #2, when I heard a commotion/disturbance around by the med window. On arrival to that site, I saw [Patient #1] and [RN #1] fighting [physically]. Also involved in the fight were [Names of Patients #2, #3, #4 and #6] ..."
RN #3 also listed the names of Behavioral Health Tech (BHT) #3 as the tech assigned to another 1:1 patient.
RN #3 documented, "...we were overwhelmed trying to diffuse the chaos and melee [a confused fight]. Sometime during this incident, [Name of BHT #1] arrived from SCU [Senior Care Unit] to help. [BHT #1] was soon thereafter attacked by several patients, and our attention was momentarily diverted from [Patient #1 to BHT #1]. [BHT #1] was ushered through the door to SCU by staff. The fight at some point was momentarily diffused. At this time, [name of Patient #1's] back was to the wall in front of the med window. I was in front of him... [name of Patient #1] nose was bloody and blood was covering his face. He then began to yell 'You fucking [derogatory N word]!...You fucking [derogatory N word]!' I hollered at him to 'Shut up fool! Shut up [Patient #1's first name]!' Naturally that started a second wave of a beat down on [Patient #1]. This took what seemed a few more minutes to diffuse. Then a 3rd wave commenced at some point. [Patient #1's name] was by now on the floor being hit, beat and kicked again. The entire time staff was yelling and attempting to stop the assault. At this point, [name of Patient #1] appeared to go unconscious and have a seizure... I yelled 'Don't hit him anymore he is having a seizure!' It was at this point I was able to be open the door to nurses station #1 and drag [name of Patient #1] into the nurses' station where he was isolated and safe. [name of Patient #1] regained consciousness and I was wiping the blood off of him and asking him what had happened and how it started. He was crying and remorseful, and said 'I'm sorry, my dad was an alcoholic and a racist. It was just the way I was raised.' I told him that I was sorry this had happened to him and I said 'Well how old are you now [name of Patient #1] 29? 'It's time that you take responsibility for your actions. You can remain a victim of your upbringing and a victim, or you can choose to rise above it. It's your choice.' He [Patient #1] also told me at this time the incident began when he threw away his meds and 'she [name of RN #1] got in my face and pointed her finger at me and yelled at me.' Also at this time [name of Patient #6] began kicking the nurses station door as hard as he could to break it down to get [name of Patient #1]. Once I got [name of Patient #1] into the nurses' station, it was only then was I able to call the Support Team [code]. Eventually security and the support staff arrived to the unit. We then cleared the area and provided a safe path to escort [name of Patient #1] from the nurses' station off the unit to the exit doors."

Review of a statement taken from Patient #1 revealed when asked what happened the patient stated that he went to get his medications, but the med they give him for bedtime makes his nose dry and hard to breathe. So he "cheeked it." Patient #1 reported, "The nurse came out yelling at him and he just 'hit her'." Then everyone else jumped on him when he started calling them the 'N-word'. Patient #1 reported "The nurse on DDU was notified of the medication side effects the patient was noting and stated she would notify the psychiatrist for any further instructions."

Review of a statement taken from Patient #1's mother revealed, "... he stated that the nurse was a demon yelling at him and he hit it... [name of Patient #1] has a history of hallucinations where he sees demons screaming at him and can become aggressive to 'fight them off' ... this is the second altercation that [Patient #1] has been in during hospitalizations, one at this facility and one at another facility with no mention of facility name."

Review of a statement from BHT #2 revealed a patient yelled, "...nurse need some help..." When BHT #2 arrived at the med area, "... [name of Patient #1] was hitting nurse [RN #1] in her face with a closed fist. [ RN #3 and BHT #3] and I pulled him off [RN #1]. [Patient #1] yelled out 'Fuck you [derogatory N word]' I'm about to beat this '[derogatory N word] ass'. That got [Patients #2, #3 and #4] upset they started kicking and hitting on [Patient #1]. [BHT #1] from SCU came over to help break up the fight. Some of the patients started attacking him [BHT #1] for no reason. [security guard] from security and nurse cam [came]. Escorted [Patient #1] off the unit. [Patient #2] was still rowdy he threw a milk crate at the House Supervisor [name of supervisor] and hit her in the right arm."

Review of a statement from BHT #3 revealed a patient yelled "...'Nurse needs some help she's fighting with a patient.' [BHT #2] and I ran to the medication station to find [Patient #1] giving full closed fist punches to nurse [RN #1]'s face. In return [RN #1] was defending herself reciprocating punches. Charge Nurse [RN #3], tech [BHT #2] and I did our very best at trying to break-up the two & [and] redirect but the attempts were failed after [Patient #1] yelled out 'fuck you [derogatory N word]. I'm about to beat this [derogatory N word] ass!' His statement provoked patients [names of Patient #2, #3 and #4]. They started kicking, punching, and folding [Patient #1]. At this point patient [Patient #1] is now being jumped by majority of patients on ITU. [BHT #1] from Senior Care unit rushed over to helped [help] and was also jumped in the process for no reason..Once the other patients were calmed down and off [Patient #1] ..." the Charge Nurse pulled Patient #1 into the charting room whom was presumed to be seizing on the floor. The statement revealed the Security Guard and RN #4 escorted Patient #1 off the unit. BHT #3's statement revealed Patient #3 was still rowdy" and was throwing a milk crate at the House Supervisor.

Review of a statement from RN #4 revealed he was working on another unit passing medications and heard an emergency code being called on the overhead speakers. The unit Charge Nurse told him not to go and, "...About 15 minutes later there was a call overhead for all male employees to come to ITU immediately... When I got to ITU there was a patient in the enclosed BHT [Behavioral Health Tech] charting area sitting up with a bloody nose/face and [RN #3] sitting there with him..." A tech informed RN #4 that "it's over." Patient #1 was quickly ushered off the unit, RN #4 was informed, "...the unit was no longer safe for him because 'the patients want to kill him. The [name of security guard] said he was taking him up front of the hospital for his safety... As I got to the front area I saw the patient sitting on the floor crying. Security then told me he was putting him in the waiting room area... so he can watch him until the house supervisor has a chance to figure out what to do with him..." RN #4 stated he and the security guard left Patient #1 in the hospital's lobby and went back to the other and once RN #4 and the security guard returned to the front waiting lobby area Patient #1 was gone and the front doors were open. RN #4 stated he could see Patient #1 running across the parking lot and headed North down the street.

6. Review of the 9/8/2021 hospital video recording of the physical abuse of Patient #1 beginning at approximately 8:41 PM revealed there were five (5) patients (Patients #1, #2, #3, #4 and #6) lined up in the confined corridor area at the nurse's medication administration window. There was no audio available with the video and the medication administration window is out of video view. The following video review observations were made:

At approximately 4 seconds into the video review, a random patient left the window area and Patient #1 approaches the medication administration window area.

At approximately 46 seconds into the video review, Patient #1 leaves the medication administration window area, has a cup in his right hand and extends his left hand over the garbage can.

At approximately 51 seconds into the video review, RN #1, wearing a facial mask, walks from the medication window area with her left arm at her side and her right arm extended and waving her right hand back and forth as she is approaching Patient #1. Patient #1 still has the cup in his right hand and walks towards RN #1, with his back to the video. RN #1's arms are not in view at this time. Patient #1's left arm comes up toward RN #1's left shoulder and then towards her mid chest area. Patient #1 appears to push RN #1 away and RN #1's right arm comes forward towards the area where Patient #1's mid chest area was. Patient #1 raises both arms toward RN #1, and what appears to be water from the cup splatters on the floor.

At approximately 55 seconds into the video review, both Patient #1 and RN #1 have both hands forward, hitting and slapping each other's face, head and chest area. They go partially out of view, towards the medication window area as they are fighting.

At approximately 1 minute and 4 seconds into the video review, BHT #2 enters the area and Random Patient (RP) #8 is observed standing in the corner leaning over the garbage can. Patient #2 enters the area just behind BHT #2. BHT #2 appears to try and get Patient #1 away from RN #1. Patient #2 starts hitting at Patient #1.

At approximately 1 minute and 7 seconds into the video review, BHT #3 enters the area and is behind Patient #2. At this time, Patient #1 has his back against the wall, BHT #2 is in front and to the right side of Patient #1, Patient #2 is front of Patient #1 and continuing to hit at Patient #1, BHT #3 is behind Patient #2 and RN #1 is on Patient #1's left side.

At approximately 1 minute and 9 seconds into the video review, Patient #4, RN #3, an un-identifiable patient, and Patient #5 enter the area. BHT #3 appears to get RN #1 away from Patient #1. Patients #2, #4 and the unidentifiable patient are hitting at Patient #1. Patient #3 enters the area. Patient #1 is observed to be on the floor at this point.

At 1:55 minutes into the video review, BHT #1 is observed to enter the area.

At approximately 2:24 minutes into the video review, all patients are removed from the area, leaving Patient #1, RN #1, BHT #1, RN #3, BHT #3 and BHT #1 in the area. RP#8 is still standing in the corner leaning on the garbage can. Patient #1 appears to still be on the floor with RN #1 and BHT #3 standing over him. RN #1 and BHT #3 back away from Patient #1 and Patient #1 sits up against the wall.

BHT #3 and RN #1 failed to end the situation and back away from Patient #1 at this time. BHT #3 is observed to point her left arm at Patient #1. RN #1 is observed to be standing by Patient #1 with her hands on her hips. Patient #1 stands up and BHT #3 pushes Patient #1 away. BHT #3 puts her left arm up and pointing at Patient #1, then points her right arm and finger in Patient #1's face and then her left finger again in Patient #1's face. RN #1 backs away and gets behind BHT #3. BHT #3 continues to point in Patient #1's face. Patient #1 lunges forward towards RN #1, BHT #3 continues to point in Patient #1's face and Patient #1 appears to be spitting towards BHT #3 and his mouth is moving. RP #8 leaves the area.

At approximately 3:12 minutes into the video review, there are Patient #1, RN #1, BHT #3 and RN #3 in the medication administration area. There was no attempt to get Patient #1 out of the area. There appears to be an argument, arms forceful going up and down from all 3 staff members and Patient #1. Patient #1 appears to be yelling at RN #1 and BHT #3 and lunges forward but was not close to RN #1 or BHT #3. BHT #3 pushes Patient #1 backwards, then Patient #1 appears to spit towards RN #1, and all appear to be continuing to argue. Then RN #1 lunges toward Patient #1 and begins to hit him. Both RN #1 and BHT #3 ensue in a fight with Patient #1. RN #3 tries to get hold of Patient #1. RP #8 renters the area, as well as the other patients that were previously in the area. Two other patients begin to hit RP #1 and the fight begins again and continues until 4 minutes and 34 seconds into the video.

At approximately 4:34 minutes into the video review, all patients leave or are taken out of the area and BHT #3 leaves the area with the patients. Patient #1 is on the floor; two (2) patients remained and were hitting Patient #1. RN #1 is observed to grab Patient #1 by the hair and pulling in towards the hallway while Patient #2 continues to hit Patient #1. RN #1 reaches down and hits Patient #1 four (4) times around the head and upper chest area.

At approximately 5:00 minutes into the video review, Patient #1 is observed to be shaking all over as if having a seizure.

At 5:03 into the video RN #1 leaves the area. BHT #3 ushers all patients out of the area, except Patient #2 remains standing over Patient #1. BHT #2 is observed to be standing at the entrance of the area appearing to keep other patients from reentering the area. Patient #2 picks his hat up off the floor and BHT #3 reappears and ushers Patient #2 out of the area.

At approximately 5:38 minutes into the video review, Patient #1 is observed to be lying on the floor shaking all over as if to be experiencing a seizure and RN #3 opens the door to the enclosed nurses' station and pulls Patient #1 into the station and RN #1 reenters and closes the door to the enclosed nurses' station.

The video ends at 6:47 minutes and RN #3 is observed to be in the enclosed nurses station standing over Patient #1.

Review of the video revealed RN #1 and BHT #3 had several opportunities to step away from Patient #1 to de-escalate the situation.

7. On 9/29/2021 at 9:00 AM while reviewing the video recording in the conference room with the hospital's Risk Manager (RM) of the 9/8/2021 fighting and abuse incident, the RM identified the other patients involved in the fighting as Patients #2, #3, #4, #5, and #6.

8. Review of the medical records of Patients #2, #3, #4 and #6 who were also involved with beating Patient #1 revealed all the patients had aggressive behaviors. (Refer to A396)

9. During an interview on 9/27/2021 at 10:30 AM with the COO, RM and QAC regarding the 9/8/2021 fighting and patient abuse incident and the COO stated the incident between Patient #1 and RN #1 occurred on 9/8/2021 and began at approximately 8:41 PM. After the incident occurred, the Security Guard (SG) and RN #4 took Patient #1 to the front lobby waiting room. The House Supervisor (HS) went to the ITU to check on RN #1. When the HS went to the ITU, the patients thought they were there to fire RN #1 and began throwing items at the HS. The SG and RN #4 left Patient #1 in the hospital's waiting lobby area and went back to the ITU to check on the HS. While the SG and RN #4 were gone, Patient #1 preyed the front doors open. When the SG and RN #4 went back to the front lobby waiting area, the front doors were open and Patient #1 was in the parking lot, headed to the street. The police were notified and they located the patient down the street around the 240 bypass intersection. EMS was dispatched to the area where Patient #1 was found. EMS "checked him out" and the police brought the patient back to the hospital. Once the patient was back at the hospital, the physician was notified at 11:30 PM and gave orders to send the patient to the ER. Patient #1 returned to the hospital after being medically cleared at Hospital #2's ER on 9/9/2021 at 1:30 PM.

In an interview on 9/27/2021 at 11:30 AM when requested to view by this surveyor, the COO stated the video recording of Patient #1 in the front lobby waiting area and the patient's elopement was not available because the hospital had not preserved the video.

In an interview on 9/27/2021 at 1:45 PM the Security Guard (SG) was interviewed and stated, "They called a code. I went to the unit, saw a white patient on the floor in the glassed room. There were other patients trying to get to him ... I called the floors for all male employees to come to the floor. I think [RN #3] was in the room with the patient. I told him we were going to get that patient out as soon as possible and don't stop until we get to the hallway. Me and [ RN #4] took the patient to the front lobby and no one got in the way. [RN #4] returned back to the unit to see if everything was calming down, there was a lot of unrest on the unit, and who was going to administer medical attention to the patient in the lobby. [RN #4] and I came back to the lobby and the patient [Patient #1] was running out of the parking lot. Called [named local police] and gave them a description. The [named local police] brought him about 15 minutes later, they found him the other side of 240 [a local highway]. It was decided to bring him back here. The police brought him into the lobby unrestrained. I am unaware of anything after that, the supervisor said ... we'll just take him back."
The SG was asked what he heard when he responded to the unit. The SG stated, "Heard loud voices, don't recall what specifically, they weren't singing Christmas Carols."

In a telephone interview on 9/27/2021 at 2:24 PM, RN #3 was asked about the fighting and abuse incident of Patient #1 on 9/28/2021 and RN #3 stated, "was charting at the time, heard a commotion and went to check. [RN #1] and [Patient #1] were fighting and the patients had jumped in, about 4 patients. There was me, [RN #1], [ BHT #2] and [BHT #3] working on the unit and around 27 patients. [BHT #3] had a 1:1 patient. [BHT #2] and I were trying to break it up. [BHT #1] came from another unit, heard the noise ... Several patients jumped on [BHT #1] when he came in to help, don't remember which patients."
RN #3 was asked what RN #1 and BHT #3 were doing during the incident. RN #3 stated, "I don't know. [Patient #1] started yelling 'the f'ing N word' and spitting."
RN #3 was asked if he knew why some of the patients got involved and RN #3 stated, "To take up for the nurse."
RN #3 was asked if he knew why the staff needed someone to take up for them and RN #3 stated, "Not enough staff, they [patients] know right from wrong."
After the incident, RN #3 stated he pulled Patient #1 into the nursing station and, "[Patient #1] appeared to be unconscious and seized for about 30 seconds. His eyes were shut and he was quivering. But watching the video later, someone said it looked like he was pushing with his feet to help. I got him in the nurses station and he come to and was helping to sit up. He started crying, saying he was sorry. [Patient #6] was the patient outside kicking the door at the nurses station. [named of Patients #2, #3 and #6] are very aggressive patients and they keep readmitting them when they come in ... The patients started throwing stuff at [named the House Supervisor] because they thought she was there to fire [RN #1] ..."
RN #3 stated Patient #1 was taken off the unit.
RN #3 stated RN #1 took the patients to smoke after the fighting and abuse incident of Patient #1 and then RN #1 left the building later that night.

In a telephone interview on 9/27/2021 at 2:50 PM BHT #2 was asked about the 9/8/2021 fighting and abuse incident of Patient #1 and BHT #2 stated it "happened on a Wednesday night at med pass ... [named a patient on the unit] He was screaming the nurse needs some help. I saw [Patient #1] hitting [RN #1]. Looked like she was trying to protect herself. We tried to break it up, [BHT #3] came to help. Patients got upset and said a man shouldn't hit a woman ... patients were on [Patient #1]."

In a telephone interview on 9/28/2021 at 8:02 AM, BHT #1 was asked about the 9/28/2021 fighting and abuse incident of Patient #1 and BHT #1 stated, "...Didn't see much, but walked on the unit and saw staff trying to stop patients acting violently. I was hit in the head several times by patients. I have no idea who hit me, there was so much going on."
BHT #1 was asked why he went to the ITU unit and BHT #1 stated, "I could hear screaming and yelling and went to try to help. Just heard the noise, not what was being said. The patient that started it screamed the 'N' word."

In an interview on 9/28/2021 at 8:11 AM, the RM stated Patient #1 was put on 1:1 observation after the 9/8/2021 incident. The RM stated none of the other patients involved in the incident had a change in their observation precautions or new behavior interventions.

On 9/28/2021 at 10:55 AM the House Supervisor (HS) working during the 9/8/2021 fighting and abuse incident with Patient #1 was interviewed via telephone regarding the incident and the HS stated, "I received a call from [RN #3] asking for more help. I sent someone over then heard the code called. Then got a call from Senior care regarding [ BHT #1's] injuries. So I went to Senior Care to check on [BHT #1]. He had some bleeding and a cut to the head. They said he looked dazed, but was ok when I got there. I sent him [BHT #1] to the ER. Heard the code and went to ITU, when I got there Mr. [Patient #1] was in the nursing station. He needed to be removed from the unit and taken to DDU. He was taken to DDU, notified the doctor and his mother... got an order to send him out to ER..."

In a telephone interview on 9/28/2021 at 1:09 PM, BHT #3 was asked about the 9/8/2021 fighting and abuse incident with Patient #1 and BHT #3 stated, "A patient and nurse were fighting, I saw the patient and nurse fighting.

Based on medical record review, hospital policies review, hospital forms review, video recording review and interviews, the hospital failed to ensure all nursing staff exhibited and utilized knowledge of the hospitals policies and procedures and ensure all the complex needs of patient could be met by the nursing staff assigned to care for the patients and new interventions were developed and implemented when care needs changed for 6 of 6 (Patients #1, #2, #3, #4, #5 and #6) sampled patients and for all the patients admitted to the hospital.

The findings included:

1. Review of a video recording revealed Patients #1, #2, #3, #4, #5 and #6 participated in a physical fighting altercation while standing in line waiting to receive their evening medications.

Review of the medical record for Patient #6 revealed the patient had cigarette paraphernalia hidden on himself and in his room and the patient caught his bed on fire which promoted the sprinkler system and the fire departments responding to the hospital. The patient stated he caught his bed on fire because he was upset about being checked on every 15 minutes.

There was no documentation in the patients' medical records that patients plans of care had been updated with new interventions developed and implemented for the patients' aggressive fighting behaviors or for Patient #6's actions of setting his bed on fire due to being upset about every 15 minute checks.
Refer to A396, A144, A145.

2. Review of the hospital's Contraband policy dated "11/2020" and the hospital Searches policy dated "3/2020" revealed to conduct an all unit room searches and/or invasive searches if contraband is suspected of Patients. The policy documented to notify the physician if the patient refuse an invasive search.

On 9/6/2021 at 8:00 PM staff noticed cigarette smoke odor coming from Patient #6's room. The staff found cigarette ashes in the patient's room, searched the patient's room and did not find cigarette paraphernalia. The staff did not follow hospital policy and procedures and conduct an invasive body search of Patient #6 or notify the patient's physician that Patient #6 refused an invasive body search.

On 9/7/2021 at 12:10 AM the hospital's fire alarm system sounded and staff found Patient #6's bed on fire.

The hospital had failed to ensure all staff followed hospital polices and procedures in order to protect patients.
Refer to A144 and A398.

2. Review of hospital's policies for medication administration policy dated "9/2021" revealed to notify the physician if a patients refused to take their medications.

Review of the hospital's policy for the prevention of abuse policy dated "10/2020 and the hospital's Special Precautions policy dated "10/2020" revealed not to trigger the patients, remain calm with patients, use de-escalating and CPI non-violent techniques to prevent abusive behaviors.

On 9/8/2021 during the evening medication pass, Patient #1, who had aggressive displays of behaviors, refused to take his night time medications. RN #1 approached Patient #1 with a finger pointed at his face and Patient #1 hit RN #1. Patients #2, #3. #4, #5 and #6 who also had displayed aggressive behaviors were in line to receive medications as well. When RN #1 and Patient #1 began physically fighting the other patients in the medication line joined in the fight. Patient #1 was removed and left unattended in the hospital's front lobby. Patient #1 was found outside of the hospital by the local policy, brought back to the hospital and then transferred to an acute care hospital to receive medical treatment. Patient #1 received medical treatment for a small abrasion to his right elbow, few abrasions on his face, bilateral periorbital small ecchymosis, right elbow tenderness with mild swelling and small ecchymosis. The patient was discharged back to the hospital after being medically cleared.

There was no observations on the video recording or documentation that RN #1 had followed de-escalating and Crisis Prevention Institute non-violent techniques per the hospital policy and procedures. There was no documentation RN #1 had been removed from the patient care area following the physical altercation with Patient
#1 per hospital policies.
Refer to A145 and A398.

Based on medical record review and video observations review the hospital failed to ensure the nursing care plan was updated in order to manage patient's aggressive behaviors for 5 of 6 (Patients #2, #3, #4, #5 and #6) patients who exhibited aggressive behaviors by participating in a physical fighting altercation with another patient (Patient #1) while waiting in line to receive their medications and 1 of 1 (Patient #6) patients who lit their bed on fire.

The findings included:

1. Review of a video recording dated 9/8/2021 revealed Patients #2, #3, #4, #5 and #6 were involved in a physical fighting altercation with Patient #1 while wafting in line to receive their medications.

2. Medical record review Patient #2 was a 35 year old African American male who was admitted to the hospital on 8/24/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks with assault precautions.

Review of the 8/24/2021 Behavioral Health Interdisciplinary Plan revealed, " ... is on AP [assault precautions] due to a history of aggression..."

Review of the Nurse Shift Reassessments dated 9/7/2021, 9/8/2021 and 9/9/2021 revealed the patient's behaviors were irritable, easily agitated mood, labile, anxious, impulsive, delusions, paranoid, verbal aggression, and/or physical aggression towards peer.

Review of the Nurse Progress Note dated 9/9/2021 revealed the House Supervisor documented, "On 09/08/2021 between 2030 [8:30 PM] and 2130 [9:30 PM], pt is reported to have engaged in punching and hitting and kicking a white patient, first for reportedly hitting a black nurse and then a second time for verbalizing racial slurs a couple of minutes after."

There was no documentation the patient's plan of care had been updated with new interventions developed and implemented for the patient's aggressive fighting behaviors or increased safety checks for Patient #2.

3. Medical record review for Patient #3 revealed the patient was a 34 year old African American male who was admitted to the facility on 8/28/2021 with the diagnosis of Schizoaffective. The patient was on every 15 minute safety checks.

Review of the 8/30/2021 Behavioral Health Interdisciplinary Plan revealed, " ... is on AP due to a history of aggression ..."

Review of the Nurse Progress Note dated 9/9/2021 revealed the House Supervisor documented, "On 09/08/2021 between 2030 and 2130, pt is reported to have engaged in punching and hitting and kicking a white patient, first for reportedly hitting a black nurse and then a second time for verbalizing racial slurs a couple of minutes after."

Review of the Patient Assessment Report dated 9/9/2021 revealed, "Counselor met with [name of patient] to discuss behaviors displayed on yesterday. [name of Patient #3] reported becoming upset following a male peer arguing with female staff ... 'I beat the white boy up' ... Patient presented with verbal aggression and reported he was a vampire. 'I like blood and I got Herpes.' [name of Patient #3] reported having no regret for aggressive interactions on unit and asked to end meet..."

There was no documentation the patient's plan of care had been updated with new interventions developed and implemented for the patient's aggressive fighting behaviors or increased safety checks for Patient #3.

4. Medical record review for Patient #4 revealed the patient was a 36 year old African American male who was admitted to the facility on 9/7/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

Review of the 9/7/2021 and 9/8/2021 Nurse Shift Reassessments revealed the patient's behaviors were easily agitated, angry, cursing, threatening staff and peers, pacing, anxious, impulsive and/or uncooperative. The 9/8/2021 4:11 note revealed the patient was administered Ativan 2mg (milligrams) for "yelling and attacking verbally other pt and staff."

Review of the 9/8/2021 Behavioral health Treatment Plan at 1:20 PM revealed, " [name of Patient #4] is on AP due to aggression ..."

Review of the Nurse Progress Note dated 9/9/2021 revealed the House Supervisor documented, "On 09/08/2021 between 2030 and 2130, pt is reported to have engaged in punching and hitting and kicking a white patient, first for reportedly hitting a black nurse and then a second time for verbalizing racial slurs a couple of minutes after."

There was no documentation the patient's plan of care had been updated with new interventions developed and implemented for the patient's aggressive fighting behaviors or increased safety checks for Patient #4.

5. Medical record review for Patient #5 revealed the patient was a 29 year old African American male who was admitted to the facility on 9/5/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

Review of the 9/6/2021 Behavioral health Treatment Plan revealed, ".. admitted with increased psychosis and mood lability. States he hears voices ... patient was aggressive at home... "

Review of the 9/8/2021 Nurse Shift Reassessments revealed the patient's behaviors were angry outbursts, labile, irritable, pacing, impulsive, and physical aggression.

There was no documentation the patient's plan of care had been updated with new interventions developed and implemented for the patient's angry outburst, physical aggression or increased safety checks for Patient #5.

6. Medical record review for Patient #6 revealed the patient was a 33 year old African American male who was admitted to the facility on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

Review of the 9/8/2021 Nurse Shift Reassessments revealed the patient's behaviors were easily agitated, impulsive, anxious, irritable, pacing and/or intrusive. The patient also started a fire in his room on 9/7/2021 because he was mad and upset (Refer to A144).

Review of the Nurse Progress Note dated 9/9/2021 revealed the House Supervisor documented, "On 09/08/2021 between 2030 and 2130, pt is reported to have engaged in punching and hitting and kicking a white patient, first for reportedly hitting a black nurse and then a second time for verbalizing racial slurs a couple of minutes after."

There was no documentation the patient's plan of care had been revised with new interventions developed and implemented for the patient's aggressive fighting behaviors or increased safety checks for Patient #6.

Refer to A144, A145, and A398.

Based on hospital policies, medical record review, and interview, the Director of Nursing failed to ensure all nurses followed the hospital's policies and procedures in order to provide safety and appropriate care for 1 of 1 (Patient #6) who was smoking in the hospital and for all patients who were at the hospital while Patient #6 was smoking in his room.

Based on hospital policy, hospital forms, the hospital's video recording, medical record review and interview, the hospital failed to ensure nursing services followed policies and procedures to protect and prevent abuse of 1 of 1 (Patient #1) patients who was abused by staff and (Patients #2, #3, #4, #5 and #6) who were waiting in line at the medication area for their medications, and failed to ensure the patients physician was notified of refusal of medication administration for 1 of 1 (Patient #1) who refused medications and was approached by the nursing staff which resulted in an altercation of abuse.

The findings included:

1. Review of the facility's "SAFETY SEARCHES" policy dated "3/2020" revealed, "Delta Specialty Hospital strives to maintain a safe and therapeutic environment for patients, visitors and staff. In order to achieve this, routine searches should be conducted on all patients on admission ... Other searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient may possess and item which is potentially hazardous. When patient safety is a factor, the Nursing Supervisor may authorize a search and then contact the physician, for those searches requiring a physician order ... Patient Search ... After admission, whenever there is reasonable cause to believe the patient may possess a potentially dangerous item, he/she may be searched at that time, with notification to the physician ...
An invasive body search may be ordered by the physician for a patient if there is reasonable cause to believe that the patient has hidden contraband in a body orifice. The patient will be placed on a 1 to 1 observation and transferred to a medical facility ...
During the patient search, remove any contraband and handle as per facility's policy on contraband disposition; report search findings to the attending physician as indicated ...
If the patient objects to the search, explain the facility's policy to the patient, stating that the search is required to maintain safety for everyone and is required prior to continued treatment at the facility ...
If the patient continues to refuse the search, the physician should be notified and one of the following may occur: If the patient is voluntary and determined not to be dangerous to himself/herself or others; he/she may be discharged AMA (Against Medical Advice)...
Room Search ... Environmental rounds are conducted daily by unit staff once per shift... If contraband is suspected on the patient unit, it may be preferable to conduct a unit-wide room search ..."

Review of the facility's "CONTRABAND" policy dated "11/2020" revealed, "...Delta Specialty Hospital is committed to a safe environment free of contraband; drugs, weapons, alcohol and other items deemed a safety risk or hazard. ... Staff will consider the following to be contraband ... Items to be secured in a designated area (e.g. property room), hospital security, or restricted from being brought in by visitors ... Cigarette lighters or matches ..."

Review of the facility's "Smoking: Privileges for Behavioral Health Patients" policy dated "11/2017" revealed, "...This is a non-smoking facility with the exception of Behavioral Health Patients. Patients receiving psychiatric and/or chemical dependency may have significant difficulty if this substance is withheld ... Smoking will be allowed only in designated outside smoking area in the courtyard ... Behavioral Health patients will have restricted smoking areas but employees will not be allowed to smoke in the Behavioral Health areas..."

(a). Medical record review revealed Patient #6, was a 33 year old male who was admitted to the facility on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar. The patient was on every 15 minute safety checks.

(b). Review of the 9/6/2021 Nursing Note at 8:00 PM revealed there was a heavy smell of cigarette smoke coming from the patients' room. Upon searching the patient's room, cigarette ashes were found around the patient's bed, in the patient's garbage can and around the patient's toilet bowl. The staff were unable to find the cigarette paraphernalia. There was no evidence the staff followed the hospital's policy and conducted a unit-wide room search, an invasive search of Patient #6, re-education about the hospital's policy, notified the patient's physician of the refusal of the invasive search, or implemented 1:1 observations to determine where the contraband may be hidden.

(c). Review of the Nursing Note dated 9/7/2021 at 12:10 AM revealed the fire alarm activated, smoke was in hallway, and the staff found Patient #6's bed ablaze. All patients were evacuated and the fire department arrived at the hospital. When Patient #6 was asked asked why he started the fire he said because, 'I was mad and upset'... Intervention q [every] 15 min checks ..."

(d). In an interview on 9/29/2021 at 1:00 PM the Chief Operating Officer (COO) stated that on 9/6/2021 Patient #6 had been smoking in his room and there was evidence of ashes in the patient's toilet bowl, around the patient's toilet and in the patient's garbage can in the bathroom. The COO stated, "The support team was called to the unit, they did a pat down and didn't find anything. The patient refused a full search ... except for a pat down, while he was still wearing his clothes." The COO stated, "could not identify where he had the cigarettes and lighter..." He [Patient #6] did later say he hid the lighter in his rectum..."

(e). When asked if Patient #6's observation precautions were increased or other interventions implemented after evidence was found that Patient #6 was smoking in his room on 9/6/2021 and the COO stated there was no documentation the physician was notified of the 9/6/2021 incident and no documentation the patient's observation/monitoring was increased.

Refer to 0144.

2. Review of the facility's "ALLEGED PATIENT ABUSE, NEGLECT, AND EXPLOITATION" policy dated "10/2020" revealed, "... Delta Specialty Hospital believes the patient has the right to be free from all forms of abuse ... All employees are required to adhere to this policy ...
PURPOSE ...To protect the patient immediately when abuse or neglect is witnessed or reported ... To ensure patients are treated with dignity and respect in accordance with the Patient's Rights ... To ensure that incidents or allegations concerning patient abuse and/or neglect are handled fairly, thoroughly, and expeditiously ...
Definitions ... Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish (CMS State Operations Manual, 2020). Abuse may be physical, sexual, verbal, or exploitive...
Neglect is considered a form of abuse and defined as the failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness (CMS State Operations Manual, 2020) ...
Serious Bodily Injury: Bodily injury, which creates a substantial risk of death or which causes serious permanent disfigurement or protracted loss or impairment if function of any bodily member organ ...
Serious Mental Injury: Psychological condition, as diagnosed by a physician or licensed psychologist, which renders a patient chronically and severely anxious, agitated, depressed, socially withdrawn, psychotic, or in reasonable fear that his/her life or safety is threatened ...
Serious physical injury: an injury that causes a patient severe pain, significantly impairs or partially impairs physical functioning, either temporarily or permanently ...
Protocol: Alleged Abuse or Neglect Occurring Within the Hospital Setting ... An employee who observes or receives notification from a patient or visitor any actions defined as abuse and/or neglect will immediately report it to the Charge Nurse ...
The Charge Nurse will intervene to ensure patient safety by separating the patient from the staff ...
The Charge Nurse will notify the House Supervisor of the allegation ...
The House Supervisor will report to the unit to initiate the investigation of the allegation. The House Supervisor will escort the staff to the Human Resources Office, if during business hours. If outside of normal HR [Human Resources] hours, the House Supervisor will escort to the nursing administration office, away from patient care areas ...
The House Supervisor will notify the Risk Manager, HRD [Human Resource Director], and CEO of the allegation. a. The staff will be placed on administrative leave pending the outcome of the investigation. The HRD or House Supervisor will obtain the staff's badge and keys and escort the staff out of the hospital ...
The patient is to be interviewed by the Chief Nursing Officer, Director of Clinical Services or Risk Manager and assessed for injuries by the Charge Nurse or CNO. This assessment will be documented in a progress note ..."

Review of the facility's "SPECIAL PRECAUTIONS" policy dated "10/2020" revealed, "... Assault Precautions ... Staff members trained in management of assaultive behavior and de-escalation techniques will complete thorough and ongoing assessments for potential of assault; implement appropriate treatment at the onset of increased patient agitation; prevent or minimize injuries if patient attempts to physically assault patients, staff, or visitors ... Upon admission, all patients will be evaluated for level of assault potential ... Risk factors for assault may include ... Previous history of violence ... Frequent arguments with others ... Command hallucinations ... Persecutory delusions ... Impulsivity ... Male gender ... Young adulthood ... Lower intellectual functioning ...
...Any changes in behavior or events which may increase potential for assaultive behavior (i.e. arguments with other patients or visitors, sexually acting out by inappropriate touching or sexual comments, hallucinations, increased paranoia, or guarded behavior, increased motor activity, ect.) ... Staff interventions for the assaultive/aggressive patient may include ... Utilization of verbal de-escalation skills ... Healthy distractions ... Use a calm conversational tone when speaking with patients ... Provide reasonable alternatives ... Offer quiet time ... Prompt the patient for their individualized relaxation skill ... Avoid the patient's identified triggers ... Use of CPI [Crisis Prevention Institute Non-Violent Intervention] techniques ... Use of PRN [as needed] medications to decrease agitation ... "

Review of the facility's "MEDICATION ADMINISTRATION AND DOCUMENTATION" policy dated "9/2021" revealed, "... Administration ...Document all refused drugs on the patient's MAR. Notification of the practitioner is also to be documented in the progress note ...Medication Administration Documentation Process ... Record and circle the scheduled time on the Medication Administration Record if for any reason any scheduled drug is not administered based on nursing assessment or patient refusal. Indicate the date, medication, dosage, time, reason, and nurse signature. Document physician notification in the Progress Note ..."

(a). Medical record review revealed Patient #1 was a 29-year-old Caucasian male was involuntarily admitted to the hospital on 9/4/2021 with the diagnosis of Schizoaffective Disorder with Bipolar, and Seizure Disorder. Patient #1 had a history of multiple psychiatric hospital admissions. The patient presented to the hospital with homicidal ideations towards his family, threatening to cut their heads off with a box cutter and burn down the house, and speaks to demons. The patient believed his father wanted to melt him with Hydrochloric Acid.

Review of hospital form revealed an fighting incident occurred on 9/8/2021 at approximately 8:41 PM after Patient #1 refused their 9:00 PM medications. The hospital form revealed the Registered Nurse (RN) #1 confronted the patient and a fight ensued between the RN, Patient #6 and other patients (Patients #2, #3, #4, #5 and #6) who were waiting in line at the medication area for their medications. There was no documentation the physician was notified of the patient's refusal of their medications. There was no documentation or observations on the video recording of the event that RN #1 followed policies and used a calm conversational tone when speaking with the patient, avoided patient triggers and used Crisis Prevention Institute (CPI) non-violent intervention techniques.

(c). Review of the 9/8/2021 hospital video recording of the physical abuse of Patient #1 beginning at approximately 8:41 PM revealed there were five (5) patients (Patients #1, #2, #3, #4 and #6) lined up in the confined corridor area at the nurse's medication administration window. There was no audio available with the video and the medication administration window is out of video view. The following video review observations were made:

At approximately 4 seconds into the video review, a random patient left the window area and Patient #1 approaches the medication administration window area.

At approximately 46 seconds into the video review, Patient #1 leaves the medication administration window area, has a cup in his right hand and extends his left hand over the garbage can.

At approximately 51 seconds into the video review, RN #1, wearing a facial mask, walks from the medication window area with her left arm at her side and her right arm extended and waving her right hand back and forth as she is approaching Patient #1. Patient #1 still has the cup in his right hand and walks towards RN #1, with his back to the video. RN #1's arms are not in view at this time. Patient #1's left arm comes up toward RN #1's left shoulder and then towards her mid chest area. Patient #1 appears to push RN #1 away and RN #1's right arm comes forward towards the area where Patient #1's mid chest area was. Patient #1 raises both arms toward RN #1, and what appears to be water from the cup splatters on the floor.

At approximately 55 seconds into the video review, both Patient #1 and RN #1 have both hands forward, hitting and slapping each other's face, head and chest area. They go partially out of view, towards the medication window area as they are fighting.

At approximately 1 minute and 4 seconds into the video review, BHT #2 enters the area and Random Patient (RP) #8 is observed standing in the corner leaning over the garbage can. Patient #2 enters the area just behind BHT #2. BHT #2 appears to try and get Patient #1 away from RN #1. Patient #2 starts hitting at Patient #1.

At approximately 1 minute and 7 seconds into the video review, BHT #3 enters the area and is behind Patient #2. At this time, Patient #1 has his back against the wall, BHT #2 is in front and to the right side of Patient #1, Patient #2 is front of Patient #1 and continuing to hit at Patient #1, BHT #3 is behind Patient #2 and RN #1 is on Patient #1's left side.

At approximately 1 minute and 9 seconds into the video review, Patient #4, RN #3, an un-identifiable patient, and Patient #5 enter the area. BHT #3 appears to get RN #1 away from Patient #1. Patients #2, #4 and the unidentifiable patient are hitting at Patient #1. Patient #3 enters the area. Patient #1 is observed to be on the floor at this point.

At 1:55 minutes into the video review, BHT #1 is observed to enter the area.

At approximately 2:24 minutes into the video review, all patients are removed from the area, leaving Patient #1, RN #1, BHT #1, RN #3, BHT #3 and BHT #1 in the area. RP#8 is still standing in the corner leaning on the garbage can. Patient #1 appears to still be on the floor with RN #1 and BHT #3 standing over him. RN #1 and BHT #3 back away from Patient #1 and Patient #1 sits up against the wall.

BHT #3 and RN #1 failed to end the situation and back away from Patient #1 at this time. BHT #3 is observed to point her left arm at Patient #1. RN #1 is observed to be standing by Patient #1 with her hands on her hips. Patient #1 stands up and BHT #3 pushes Patient #1 away. BHT #3 puts her left arm up and pointing at Patient #1, then points her right arm and finger in Patient #1's face and then her left finger again in Patient #1's face. RN #1 backs away and gets behind BHT #3. BHT #3 continues to point in Patient #1's face. Patient #1 lunges forward towards RN #1, BHT #3 continues to point in Patient #1's face and Patient #1 appears to be spitting towards BHT #3 and his mouth is moving. RP #8 leaves the area.

At approximately 3:12 minutes into the video review, there are Patient #1, RN #1, BHT #3 and RN #3 in the medication administration area. There was no attempt to get Patient #1 out of the area. There appears to be an argument, arms forceful going up and down from all 3 staff members and Patient #1. Patient #1 appears to be yelling at RN #1 and BHT #3 and lunges forward but was not close to RN #1 or BHT #3. BHT #3 pushes Patient #1 backwards, then Patient #1 appears to spit towards RN #1, and all appear to be continuing to argue. Then RN #1 lunges toward Patient #1 and begins to hit him. Both RN #1 and BHT #3 ensue in a fight with Patient #1. RN #3 tries to get hold of Patient #1. RP #8 renters the area, as well as the other patients that were previously in the area. Two other patients begin to hit RP #1 and the fight begins again and continues until 4 minutes and 34 seconds into the video.

At approximately 4:34 minutes into the video review, all patients leave or are taken out of the area and BHT #3 leaves the area with the patients. Patient #1 is on the floor; two (2) patients remained and were hitting Patient #1. RN #1 is observed to grab Patient #1 by the hair and pulling in towards the hallway while Patient #2 continues to hit Patient #1. RN #1 reaches down and hits Patient #1 four (4) times around the head and upper chest area.

At approximately 5:00 minutes into the video review, Patient #1 is observed to be shaking all over as if having a seizure.

At 5:03 into the video RN #1 leaves the area. BHT #3 ushers all patients out of the area, except Patient #2 remains standing over Patient #1. BHT #2 is observed to be standing at the entrance of the area appearing to keep other patients from reentering the area. Patient #2 picks his hat up off the floor and BHT #3 reappears and ushers Patient #2 out of the area.

At approximately 5:38 minutes into the video review, Patient #1 is observed to be lying on the floor shaking all over as if to be experiencing a seizure and RN #3 opens the door to the enclosed nurses' station and pulls Patient #1 into the station and RN #1 reenters and closes the door to the enclosed nurses' station.

The video ends at 6:47 minutes and RN #3 is observed to be in the enclosed nurses station standing over Patient #1.

There was no observations on the video the staff used de-escalating techniques or CPI techniques to divert the fighting incident between staff and patients.

(d). A late entry House Supervisor note dated 9/8/2021 at 12:15 PM revealed on 9/8/2021 after the physical fighting altercation between RN #1, Patient #1 and Patients # #1, #2, #3, #4 and #6, Patient #1 was removed from the other patients and left unattended in the front lobby of the hospital. The House Supervisor documented that, "Pt is shaking, appears to be in pain and has blood covering his face...". The House Supervisor documented the local police were called who found Patient #1 walking along a stretch of a major bypass. Patient #1 was brought back to the hospital and transferred to an acute are hospital where the patient remained the rest of the night.

(e). Review of the acute care hospital (Hospital #2) Emergency Department (ED) report for Patient #1 revealed the patient arrived at the ED on 9/9/2021 at 12:53 AM. The ED physician documented the patient was seen immediately on arrival. The ED physician documented the patient presented for "... assault- punched in the face, short seizure after assault... possible LOC [loss of consciousness] ... stated that he was assaulted ...because he refused to take medication ...stated he was beaten pretty badly... the patient became tearful while obtaining H&P [history and physical], stated he was raped all his life..." The ED physician documented the patient had a small abrasion to his right elbow, few abrasions on his face, bilateral periorbital small ecchymosis, right elbow tenderness with mild swelling and small ecchymosis. The patient was discharged back to the hospital after being medically cleared.

(f). In a telephone interview on 9/28/2021 at 3:31 PM, RN #1 was asked about the 9/8/2021 fighting and abuse incident with Patient #1 and RN #1 stated, "I was not having problems, I was passing meds. It was my first time working with Mr. [named Patient #1]. He turned around and disposed of the meds, threw the meds in the garbage. I made an announcement that cigarette smoking is a privilege, as a public announcement. I blacked out and can't remember everything that happened. We didn't have enough staff. I was attacked and lost my mind. At that point I was attacked, cuz I had my foot in the door... the med room door I believe. I just remember getting punched several times before I started fighting back."
RN #1 was asked if she was passing medications through a window with the door shut and RN #1 stated, "UhHuh."
RN #1 clarified that she gave Patient #1 his meds and he turned around and disposed of them. RN #1 stated, "UhHuh, and immediately walked away. He didn't think I saw him. We have patients try to cheek the meds, try to throw them away, try to cup them. He didn't think I saw him. So, I opened the door and made the announcement, because there was a line of patients. He turned around like he was going to come back and comply. He punched me 2 or 3 times. Uh, and at that point I just started fighting back."
RN #1 was asked if Patient #1 became aggressive toward her after she said smoking was a privilege and that they needed to take their meds if they wanted to smoke and RN #1 stated, "Yeah, he turned around and came back like he was going to comply. He hauled off and started punching me. I kinda lost it, I don't even deal with that in my regular everyday life, being punched in the face by a man. I remember a patient saying, 'he's fighting the nurse, he's fighting the nurse.' A patient that I have a great rapport with, they came over and played Behavior Health Tech. They jumped on him. At that point in time, I tried to get them off of him. One said, 'you're bleeding, you're bleeding.' I kinda lost it again. [Patient #1] looked at me and said 'Fuck you, you [derogatory N word]' in my open wounds. And I lost it again."
RN #1 was asked what happened after that and RN #1 stated, "Well from other peers, in the next day or two my peers were calling me to let me know the video was shown to them, and I attacked him while he was down, like twice. So, you know I lost my mind too. I said to my coworkers, at what point does my sanity come into play. I'm overworked and understaffed. Just insane, there was a domino effect. I've never ever betrayed that type of behavior. My patients love me."
RN #1 was asked if they had training to handle this type of behavior and RN #1 stated, "Yes, I've had training, we've all had training. I've had CPI, deal with it every day. It's just hard to say what you will do in that situation. Those licks were pretty hard. I do want to leave work the way I came in I don't want to leave with no missing teeth, you know. I just lost, blacked out. I'm embarrassed and ashamed. I didn't press any charges on the patient. I was in the wrong too."
RN #1 was asked if there was anything else they would like to add and RN #1 stated, "Yes ma'am. It could have been prevented, there's no reason I should go to work and feel unsafe. We have one tech and thirty patients. I shouldn't go to work and worry about like, being punched in the face by a man. Myself and my coworkers have voiced this over and over with Delta Specialty Hospital. It was my time, this time. I'm not the only one. I'm a nurse and I am supposed to be more competent. [RN #3] was working...has a bad leg. He's an elderly nurse, he's kinda old. He can't be out there trying to play tech with these young mental patients. We told... supervisors time and time again we need help, those patients run supervisors off the floor. I did uhm, just couldn't take it anymore. I quit, I'm done, I quit... I did compose myself and came back and got that unit under control. Took those patients out to smoke and just calmed everything down before I left. After that, I just went on and left. No one else can control those patients, no supervisors or [named RN #3]. They have a rapport with me. I just hate for that to be on my record, instead of all the good I've done. You know, they call me every night to come in because they don't have nurses. I do want it documented that it was out of character for me."

There was no documentation RN#1 was immediately taken from the patient care area and escorted to the nursing office per the hospital policy. RN #1 was allowed to remain in the patient care area and smoke cigarettes with the other patients who were a party to the fighting incident with Patient #1.

(g). Review of the hospital's investigation of the fighting/abuse incident between RN #1 and Patient #1 revealed RN #1 had confronted Patient #1 for throwing away his medication, and Patient #1 struck RN #1. RN #1 then began hitting Patient #1 back at which time a fight ensued with Patients #2, #3, #4, #5 and #6 joining in the fight and hitting Patient #1. The hospital documented that RN #1 had failed to remove herself from the incident and continued to engage in a physical altercation with Patient #1 and RN #1 did not follow hospital polices medication refusal.
The hospital's investigation documented that BHT #3 did not follow hospital polices and was observed during the video review to be aggressive in pointing towards the patient and inappropriately intervening when the patient made physical advances. BHT #3 was placed on administrative leave pending completion of a CPI refresher course.

Refer to 0145.