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Based on record review and interview, the hospital failed to ensure 2 of 3 patients (Patient #2 and #3) received care in a safe setting in that each of the patients were hit by a peer (Patient #1 and Patient #4) on two separate occasions.

Findings Included:

1) Patient #2's medical record included that she was asleep in her room on 11/14/11 when Patient #1 came into the room and hit her in the face.

The 11/14/11 nursing note timed at 14:40 PM reflected, "sitting in the nurse's station and heard a scream from patient's room. A mental health technician and material management staff were in the room on each side of (Patient #1), and (Patient #2) was crawling down the bed. The patient had less than 1 cc (cubic centimeters) of blood going down the right side of her face...approximately one inch scratch was cleaned with saline...Band-Aid was placed on it..at 14:51 PM the physician assistant assessed the patient for a broken nose with no additional injuries noted.."

2) Patient #3's medical record included that on 10/20/11 he had been verbally abusive and threatening in PES (psychiatric emergency services). Patient #4 got out of his chair and hit Patient #3 in the face.

The medical record reflected, on 10/20/11 at 07:26 AM Patient #3 was disruptive, agitated, cursing at staff and peers on the unit. He attempted to start fights...at 12:07 PM he was administered Ativan, Benadryl and Haldol for aggression and agitation...at 13:37 PM the patient was in his wheelchair cursing at other patients and threatening to beat up staff and peers...he threw a bottle of water at a staff member...a peer (Patient #4) got out of his chair and hit (Patient #3). (Patient #3) was sent to the medical hospital...to close the laceration over the eye..."

In an interview with the surveyor at 14:00 PM on 02/08/12 the CNO/COO (Employee #1) confirmed that patients #2 and #3 were hit by other patients.

Based on record review and interview, the hospital failed to ensure 2 of 3 patients (Patient #2 and #3) received care in a safe setting in that each of the patients were hit by a peer (Patient #1 and Patient #4) on two separate occasions.

Findings Included:

1) Patient #2's medical record included that she was asleep in her room on 11/14/11 when Patient #1 came into the room and hit her in the face.

The 11/14/11 nursing note timed at 14:40 PM reflected, "sitting in the nurse's station and heard a scream from patient's room. A mental health technician and material management staff were in the room on each side of (Patient #1), and (Patient #2) was crawling down the bed. The patient had less than 1 cc (cubic centimeters) of blood going down the right side of her face...approximately one inch scratch was cleaned with saline...Band-Aid was placed on it..at 14:51 PM the physician assistant assessed the patient for a broken nose with no additional injuries noted.."

2) Patient #3's medical record included that on 10/20/11 he had been verbally abusive and threatening in PES (psychiatric emergency services). Patient #4 got out of his chair and hit Patient #3 in the face.

The medical record reflected, on 10/20/11 at 07:26 AM Patient #3 was disruptive, agitated, cursing at staff and peers on the unit. He attempted to start fights...at 12:07 PM he was administered Ativan, Benadryl and Haldol for aggression and agitation...at 13:37 PM the patient was in his wheelchair cursing at other patients and threatening to beat up staff and peers...he threw a bottle of water at a staff member...a peer (Patient #4) got out of his chair and hit (Patient #3). (Patient #3) was sent to the medical hospital...to close the laceration over the eye..."

In an interview with the surveyor at 14:00 PM on 02/08/12 the CNO/COO (Employee #1) confirmed that patients #2 and #3 were hit by other patients.