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Based on review of policy, medical records, video surveillance reveiw, and staff interviews, the hospital's nursing staff failed to protect and promote Patients' Rights by failing to ensure care in a safe setting for 2 of 2 patients (Patients #6 and #11).

Review on 05/10/2017 of the "Code White Psychiatric Emergency", revised 12/2012, revealed, " ...A. Calling the Code The staff member who observes the need for assistance with persons who are exhibiting out-of-control behavior such as ..., injure themselves or others, ... At the scene, the charge nurse assumes responsibility for managing the code and the safety of the environment. This includes: 1. Assessing the need for verbal de-escalation, medication intervention ...7. Every effort is made to utilize verbal and chemical interventions to de-escalate a violent person. ..."

1. Closed medical record review on 05/09/2017 for Patient #6 revealed a 53 year-old presented to the facility via emergency medical service (EMS) on 03/24/2017 under Involuntary Commitment (IVC) following a suicide attempt with complaints of command auditory hallucination voices to kill himself and others and discharged 04/04/2017. Review on 05/09/2017 of the "PSYCHIATRIC EVALUATION and History and Physical" by the Psychiatrist (MD #1) on 03/25/2017 at 1300 revealed, "... hx (history) of PTSD, bipolar, and schizophrenia ...PTSD from military deployment ... ADMITTING DIAGNOSIS (DSM 5) 1. Schizoaffective d/o (disorder), bipolar type 2. PTSD 3. Etoh (alcohol) abuse, in early remission ..." Continued review revealed admission to Unit A. Review revealed a physician order, on 04/02/2017 at 0715 by MD #3, to "transfer patient to ED" (emergency department). Continued review revealed a nursing progress note on 04/02/2017 at 1035 by the 7a-7p registered nurse (RN #3) stating, "Pt (patient) and another male (Patient #11) in community room (located directly in front of the nursing station) being verbally aggressive. This pt. picked up a coffee container as if to swing it like a weapon. This was taken away from him. Then pt. picked up a chair as if to throw it. Pt. was told to put it down and he did. That's when the other patient (#11) started to chant "Code White, Code White" (code used to notify the need for additional staff). The other patient (#11) started to punch this patient in the head and face. He was pulled off pt. but turned around and kicked pt. in the head. Pt's pulled apart. Pt. sent to ED to rule out concussion broken nose [sic]. Continued review of nursing progress notes revealed a note by RN #5 on 04/02/2017 at 1300 stating, "Pt. returned from hospital. Pt. has sutures to right eye. Review of a physician note by MD #3 04/03/2017 at 0132 revealed, "I. Presentation: (Named patient) was seen today. ... He apparently got into a conflict, verbal argument with a fellow patient who was acutely manic got assaulted and had to be taken to (hospital name) Emergency Room (ER) early this morning. He sustained a laceration above his left eyebrow and a fracture of his nasal bone along with bruise of the orbital bone. ... II. Status Changes and Justifications ...: At this point he is separated from the guy (Patient #11) he got into a physical argument with and he is put in [sic] different unit (Unit C). He is all hiked up [sic]. His pride got hurt that he was assaulted by a fellow patient. ...He clearly is very agitated and irrational. ..."

2. Closed medical record review on 05/09/2017 for Patient #11 revealed a 25 year-old presented to the facility under IVC on 03/28/2017 in a hypermanic state with complaints of inability to sleep for 2 days, intrusive behaviors and sense of boundaries. Review revealed the patient was non-compliant with his medication regime and was not taking his Lithium (used to stabilize manic behavior). Review of a physician note by MD #1 on 03/31/3017 (no date) revealed the patient was delusional, had pressured speech, "grandiose (absurd exaggeration) and illogical" with "poor insight. ..." Review of a progress note by MHT #5 on 04/02/2017 at 0730-0800 revealed, "Pt. was aggravated and talking about his fight with another patient (patient #6). ... 0800-0900 ... Woke once ... to ask for ice for his hand and foot (hit another patient with hand and foot). ...0900-1000 ...had his foot examined by nurse. ..." Review of a nursing note on 04/02/2017 at 1035 by the 7a-7p registered nurse (RN) #3 stating, "Pt and another pt. (male) (patient #6) were in community room (located directly in front of the nursing station) being verbally aggressive. The other pt (patient #6) picked up a coffee container as if to swing it like a weapon. This was taken away. Then the other pt (patient #6) picked up a chair. Pt. was told to put it down. This pt. started to chant "Code White, Code White." That's when this pt. started to punch the pt. (patient #6) in the head and face. He was pulled off pt. (patient #6) but turned and kicked him in the head. Pt's pulled apart. This pt. given Geodon IM and Benadryl IM. Mobile X ray ordered for ® (right) hand & ® foot." Review failed to reveal documentation of events leading up to the physical altercation between this patient and patient #6. Review failed to reveal nursing documentation of the injury i.e., swelling, discoloration, deformity etc. Review revealed a physician order by MD #1 on 04/02/2017 at 0720 for 1:1 at all times (staff remains with patient at all times and documents on the patient safety rounds sheet every 7 minutes) and discontinued 04/03/2017 at 1800 by MD #1. Continued review of orders by MD #3 on 04/02/2017 at 0950 revealed orders for an x-ray of the ® foot, ® hand and arm for pain. Review revealed a radiology report dated 04/02/2017 at 2138 (~ 12 hours, 38 minutes after the MHT note indicating the patient requested ice for his hand and foot) for "SWELLING/PAIN" revealed, " ... RIGHT FOOT ... Findings: No acute fracture ...Small talar (ankle bone) break. ...RIGHT HAND ... Findings: No acute fracture ... Soft tissue swelling is seen. Review failed to reveal nursing documentation of the patient's injuries or of reassessment. Review of a physician's note on 04/02/2107 at 1254 by MD #3 revealed "... (Patient name) was seen today. He is extremely manic, agitated, and grandiose. He was aggressive with a fellow patient because of a conflict between them. ...He is on one-to-one to prevent aggressive behavior at present time.

Review on 05/09/2017 at 1500 of video surveillance of Unit B on 04/02/2017 at approximately 06:53:00 - 07:01:00 with the risk manager (RM) and DON revealed:
- 06:55:29 Patient #11 walked over to patient #6 and attempted to hug him in the dayroom.
- 06:55:30 Patient #6 immediately began backing away. There was a verbal exchange from patient #6 who is shaking his head no, and pointing his finger at patient #11 while holding a cup of coffee in the same hand.
- 06:55:53 The 7a-7p nurse (RN #3) walked onto the unit. Patient #6 walked to the end of the row of chairs and started to walk around but patient #11 began walking down toward him, and patient #6 walked back up the row away from him. Patient #11 walked back up and stood directly in front of him on the opposite side of the chairs. Patient #6 is observed pacing back and forth and holding his arm out at times and up at others. Both continue to verbally engage one another. MHT #1. MHT #1, MHT #2 and RN #3 look in the direction of where patient #6 and #11 are standing.
- 06:56:04 Patient #6 backed up again, shaking his head "No", pacing side-to-side, waving his left arm, finger pointed.
- 06:56:18 Patient #11 walked over and sat down in chair #1, closest to the nursing station and patient #11 stood in front of chair #4 in the row, furthest from the nursing station. Patient #6 was observed with legs crossed, rapidly shaking his foot. The verbal exchange continued. MHT #1, MHT #2, and RN #3 continued to watch the verbal exchange between patient #6 and #11.
- 06:56:37 Patient #11 began dancing in front of #6.
- 06:56:43 Patient #6 got up from the chair, walked over to the nursing station.
- 06:56:51 Patient #6 reached over the counter and picked up a stainless steel coffee dispenser while swinging it at his side. MHT #1 and MHT #2 are observed on the video watching as patient #6 picked the coffee dispenser up. Patient #6 stood at the nursing station briefly, began walking toward Patient #11 and stopped. Patient #11 was observed standing in the dayroom, talking to a peer.
- 06:56:55 MHT #2 observed getting up from a seated position and held her hand out. Patient #6 put the coffee dispenser back on the nursing desk and MHT #2 walked over and moved it from within reach.
- 06:57:01 MHT #1 remained in the same position, leaned over the nursing station counter, looking up periodically in the direction of the dayroom where the patients are observed having verbal exchange.
- 06:57:06 Patient #6 walked directly from the nurse's station and threw coffee, according to staff interview, on/at patient #11.
- 06:57:10 Patient #6 picked up a wooden chair and raised it to his mid-chest area. MHT #1 observed in the same position, leaning over the nursing station desk.
- 06:57:13 Patient #6 put the chair down, after a verbal prompt from RN #3 according to interview. MHT #1 began walking toward the direction of the dayroom and stood at the end of the nursing station counter but did not come around to the side where patient #6 and #11 were located.
- 06:57:18 Patient #6 walked over to #11 and hit him in the stomach, verbal exchange continued. The verbal exchange intensifies with notable change in expression and body language. MHT #1 remains standing at the end of the nursing station and RN #2 is observed at the nursing station, looking at patient #6 and #11. Observation revealed nursing staff did not attempt to physically separate the patients.
- 06:57:21 Patient #6 bent forward and ran toward to #11, striking him in the right thigh with his left shoulder. Patient #11 swung at patient #6 and missed initially. Patient #6 immediately began striking #11. Patient #11 pushed Patient #6 and a physical altercation ensued.
- 06:57:24 The physical patient-to-patient altercation between Patient #6 and Patient #11 continued to escalate. Observation revealed staff did not attempt to physically separate the patients.

Interview on 05/09/2017 at 1545 with the DON revealed documentation for any patient on Level II precautions, regardless of cause, is every 7 minutes. Interview revealed the hospital's observation policy does not specify that every 7 minutes checks are required for Level II precautions but it is the expected protocol. Interview revealed nursing staff are trained to do every 7 minute checks for Level II precautions during orientation and have annual competencies on same. Interview revealed patient #6 was placed on Level II observation upon return from the ED on 04/02/2017 at 1200 for safety. During review of the medical record, the DON confirmed staff failed to document on the safety rounds sheet every 7 minutes. Not really sure how to incorporate this. There was no MD order for 1:1 but DON insists patient was maintained on 1:1.Interview on 05/10/2017 at 0905 with RN #1 (7p-7a nurse) with the DON present, revealed 16 years of nursing experience, including 6 years of psychiatric nursing. Interview revealed nursing staff received Crisis Prevention Intervention (CPI) training on orientation and annually thereafter. Interview revealed de-escalation techniques and skills are taught during the training. Interview revealed staff are taught that early intervention is the key to successful de-escalation. Interview revealed as soon as the patient begins to show symptoms such as "yelling, being loud, pacing, crying" staff should "be with the patient immediately" and call a Code White emergency. Interview revealed when a patient attempts to harm themselves or someone else, Code White is called using "walkie-talkies" and overhead page. Interview revealed, "If I had a Code White, I would be the team lead. Interview revealed RN #1 was in the back of the nursing station, waiting to give shift report, and could not hear the altercation between patient #6 and patient #11. Interview revealed RN #2 attempted to call a Code White via his "walkie-talkie" but it did not transmit clearly. Interview revealed RN #1 paged Code White overhead. Interview revealed, "I think we did our best" with the situation. "I think they (MHT #1 and MHT #2 should have done better." Interview revealed, RN #1 did not report details of the episode to RN #3, the oncoming nurse because she was "not aware" of what transpired. Interview revealed RN #1 thought MHT #1 and MHT #2 should have attempted de-escalation techniques "sooner" to diffuse the escalating behaviors between patient #6 and patient #11.

Interview on 05/10/2017 at 1120 with MHT #3 during tour of Unit B revealed a history of 9 years of psychiatric experience. Interview revealed staff are trained to move patients away from the agitating factor or to remove it, if possible. Interview revealed staff are trained to intervene early, at the first sign of patient-to-patient altercation before the situation escalates and get out of hand.

Interview on 05/10/2017 at 1240 with the patient advocate revealed she received a call and was asked to talk with patient #6 and had a face-to-face conversation with him "sometime that same week" (week of altercation). Interview revealed patient #6 felt the incident "could have been avoided" if staff had acted more quickly. Interview revealed patient #6 stated he "wished they would have broken it up faster, was upset because he got hurt and wanted to know if we would pay for his medical bills." Interview revealed the advocate's concerns following her investigation were staff's "response time". Interview revealed she questioned what alternates were provided to avoid patient-to-patient altercation, timeliness of staff intervention, de-escalation attempts. "What did we do? Did we stand around too long?"

Interview on 05/10/2017 at 1310 with RN #3 (7a-7p nurse) with the DON present, revealed when she walked onto the unit she remembered thinking it was early for patient #6 and patient #11 to be "talking as they were". Interview revealed she stopped as asked MHT #1 what was going on but could not recall what he said. Interview revealed she entered the nursing station, sat her "stuff" down and walked around the reporting section where RN#1 and RN #2 were sitting, waiting to give report. Interview revealed she asked what was going on and both RN #1 and RN #2 said the two were out there having a conversation. Interview revealed RN #3 she walked out into the open area of the nursing station "because it seemed like more than just a conversation." Interview revealed RN #3 believed the situation was "escalating" by the tones of their voices. Interview revealed RN #3 "was gonna go ahead and do report but things started to happen. MHTs were coming in for first shift. (Patient #6 name) picked up a chair and I said, 'No, No, No, you can't do that'. (RN #1 name) went to the phone and called a Code White." Interview revealed a Code White is called when additional staff are needed to maintain a safe environment and that all efforts are made to get those involved "away from each other". Interview revealed RN #3 opened the door into the dayroom, stepped out and prompted patient #11 to calm down and to stop his behavior. Interview confirmed escalating behaviors were noted as she walked through the unit to the nursing station.

Interview on 05/10/2017 at 1415 with the nurse manager revealed he received report from the night supervisor but did not understand the sequence of events and how the altercation escalated. Interview revealed he called RN #3 (7a-7p nurse) but still not know how the situation escalated in the manner that it did. Interview revealed he called RN #2 (7p-7a nurse) to determine what happened prior to first shift nursing staff coming onto the floor and activation of the Code White. Interview revealed RN #2 stated they (RN #1 and RN #2) were "back in the nursing station getting report" and could not tell him how the escalation progressed. Interview revealed the nurse manager watched the video surveillance and thought "they (nursing staff) took a little too long" to respond to the escalating behaviors. Interview revealed being "pro-active is key. We teach and tell people when to step in." Interview revealed, "I wondered where they were. I think (MHT #1 name) was shocked and scared." Interview revealed "verbal de-escalation is the first line of defense." Interview confirmed nursing staff failed to intervene when patient #6 and patient #11 began to escalate.

Interview on 05/10/2017 at 1445 with MHT #4 and the human resource director (HR) revealed both are trained CPI instructors. Interview revealed that when patients began "arguing" staff should "intervene immediately, separate and talk to them." Interview revealed both CPI trainers watched video surveillance and followed up with MHT #1 and MHT #2. MHT #2 reported she instructed (patient #6 name) "to put the chair down". Interview revealed MHT #1 and MHT #2 but did not intervene when patient #6 picked the chair up, resulting in a "missed opportunity" to implement de-escalation techniques to diffuse the situation. The HR stated staff are taught to "get between them (patients). Our job is to ensure patient safely." Interview revealed MHT #1 was retrained on de-escalation techniques according to CPI. MHT #4 stated in his "opinion, (MHT #1 name) was afraid of (patient #11 name) but I told him he has to get help." Interview revealed other nursing staff present during the altercation between patient #6 and patient #11 did not receive additional CPI training following the patient-to-patient altercation. Interview confirmed nursing staff failed to intervene when patient #6 and patient #11 began to escalate.

Interview on 05/10/2017 at approximately 1500 with the DON revealed the focus of administrative review was with the MHT's failure to respond to the escalating situation, "Because they (MHT #1 and MHT #2) were present." Interview revealed there was no additional training for other staff members present during the altercation between patient #6 and patient #11 did not receive additional CPI training following the patient-to-patient altercation. Interview revealed plans to conduct a "case study" using the patient-to-patient altercation between patient #6 and patient #11. Interview revealed as part of the review, nursing staff will be reminded that they "can't wait until the situation escalates. I think they (RN #1 and RN #2) got so caught up in report" and were not aware of the increasing aggressive behavior in the dayroom. Interview revealed nursing staff are taught "to respond to anything. We're here to take care of patients." Interview revealed, "No retraining (for nurses) was indicated at the time" during or following the investigation. Interview revealed all nursing staff present during the patient-to-patient altercation between patient #6 and patient #11 did not receive additional CPI training.

Based on review of policy and procedure review, medical record review, patient safety round flow sheets, video surveillance review, and staff interviews, the registered nurse (RN) failed to provide supervision and evaluation of nursing care by the mental health technicians (MHT) to ensure safety checks were performed according to physician's orders for 3 of 5 patients (Patients #5, #6, and #11) on Level II precautions (every 7 minutes); and failed to document assessment of patients for injury after a patient-to-patient physical altercation for 2 of 2 patients (Patients #6, #11).

The findings include:

Review on 05/10/2017 of the "Nursing Assessment and Reassessment" policy, reviewed 04/2016, revealed, "POLICY... Reassessment is conducted on each shift and when a change in the patient's condition occurs. ...1.1 Ongoing reassessments are conducted by a Registered Nurse as warranted by the patient's condition. ..."

Review on 05/10/2017 of the "Patient Observation Policy", revised 01/2016, revealed, " ...To ensure patient safety ... Nurse/Nursing Supervisor: ...a. Assigns responsibility for completion of 15 minute/7 minute patient observation rounds ... c. Ensures the Patient Observation Rounds are occurring as ordered ...m. Utilize chain of command to communicate patient care concerns. Notify nurse on duty when patient exhibits high-risk behavior(s), e.g....increased agitation ..."

Review on 05/10/2017 of the " ...Restraint/Seclusion", reviewed 02/2015, revealed, " ...2.0 Staff Training and Competence Assessment: Direct care staff and RNs are required to attend altercation management training ... 2.1 ...all direct care staff ... receive on-going training and demonstrate understanding of: ...2.1.4 Alternate techniques to redirect a patient, engage the patient in constructive discussion or activity, or otherwise help the patient maintain self-control and avert escalation. ..."

Review on 05/10/2017 of the "Code White Psychiatric Emergency", revised 12/2012, revealed, " ...A. Calling the Code The staff member who observes the need for assistance with persons who are exhibiting out-of-control behavior such as ..., injure themselves or others, ... At the scene, the charge nurse assumes responsibility for managing the code and the safety of the environment. This includes: 1. Assessing the need for verbal de-escalation, medication intervention ...7. Every effort is made to utilize verbal and chemical interventions to de-escalate a violent person. ..."

1. Closed medical record review on 05/09/2017 for Patient #6 revealed a 53 year-old presented to the facility via emergency medical service (EMS) on 03/24/2017 under Involuntary Commitment (IVC) following a suicide attempt with complaints of command auditory hallucination voices to kill himself and others and discharged 04/04/2017. Review on 05/09/2017 of the "PSYCHIATRIC EVALUATION and History and Physical" by the Psychiatrist (MD #1) on 03/25/2017 at 1300 revealed, "... hx (history) of PTSD, bipolar, and schizophrenia ...PTSD from military deployment ... ADMITTING DIAGNOSIS (DSM 5) 1. Schizoaffective d/o (disorder), bipolar type 2. PTSD 3. Etoh (alcohol) abuse, in early remission ..." Continued review revealed admission to Unit A. Review revealed a physician order, on 04/02/2017 at 0715 by MD #3, to "transfer patient to ED" (emergency department). Continued review revealed a nursing progress note on 04/02/2017 at 1035 by the 7a-7p registered nurse (RN #3) stating, "Pt (patient) and another male (Patient #11) in community room (located directly in front of the nursing station) being verbally aggressive. This pt. picked up a coffee container as if to swing it like a weapon. This was taken away from him. Then pt. picked up a chair as if to throw it. Pt. was told to put it down and he did. That's when the other patient (#11) started to chant "Code White, Code White" (code used to notify the need for additional staff). The other patient (#11) started to punch this patient in the head and face. He was pulled off pt. but turned around and kicked pt. in the head. Pt's pulled apart. Pt. sent to ED to rule out concussion broken nose [sic]. Continued review of nursing progress notes revealed a note by RN #5 on 04/02/2017 at 1300 stating, "Pt. returned from hospital. Pt. has sutures to right eye. Pt. agitated, Zyprexa given. Pt. yelling, calling 911. Pt. placed on phone restrictions ...Staff verbally redirects pt. and verbally deescalate pt. ..." Review failed to reveal nursing documentation of assessment prior to transfer to the ED or upon return. Review of a physician note by MD #3 04/03/2017 at 0132 revealed, "I. Presentation: (Named patient) was seen today. ... He apparently got into a conflict, verbal argument with a fellow patient who was acutely manic got assaulted and had to be taken to (hospital name) Emergency Room (ER) early this morning. He sustained a laceration above his left eyebrow and a fracture of his nasal bone along with bruise of the orbital bone. ... II. Status Changes and Justifications ...: At this point he is separated from the guy (Patient #11) he got into a physical argument with and he is put in [sic] different unit (Unit C). He is all hiked up [sic]. His pride got hurt that he was assaulted by a fellow patient. ...He clearly is very agitated and irrational. ..." Review failed to reveal every 7 minute safety rounds check following the patient's return from the ED on 04/02/2017 at 1200 until 04/03/2017 at 0900 per MD #1 order to discontinue all precautions.

2. Closed medical record review on 05/09/2017 for Patient #11 revealed a 25 year-old presented to the facility under IVC on 03/28/2017 in a hypermanic state with complaints of inability to sleep for 2 days, intrusive behaviors and sense of boundaries. Review revealed the patient was non-compliant with his medication regime and was not taking his Lithium (used to stabilize manic behavior). Review of a physician note by MD #1 on 03/31/3017 (no date) revealed the patient was delusional, had pressured speech, "grandiose (absurd exaggeration) and illogical" with "poor insight" stated, "I am here to help people" ...I am a leader and captain. ..." Review of a progress note by MHT #5 on 04/02/2017 at 0730-0800 revealed, "Pt. was aggravated and talking about his fight with another patient (patient #6). ... 0800-0900 ... Woke once to ...and ask for ice for his hand and foot (hit another patient with hand and foot). ...0900-1000 ...had his foot examined by nurse. ..." Review of a nursing note by the 7a-7p RN (RN #3) on 04/02/2017 at 1035 by the 7a-7p registered nurse (RN) #3 stating, "Pt and another pt. (male) (patient #6) were in community room (located directly in front of the nursing station) being verbally aggressive. The other pt (patient #6) picked up a coffee container as if to swing it like a weapon. This was taken away. Then the other pt (patient #6) picked up a chair. Pt. was told to put it down. This pt. started to chant "Code White, Code White." That's when this pt. started to punch the pt. (patient #6) in the head and face. He was pulled off pt. (patient #6) but turned and kicked him in the head. Pt's pulled apart. This pt. given Geodon IM and Benadryl IM. Mobile X ray ordered for ® (right) hand & ® foot." Review failed to reveal documentation of events leading up to the physical altercation between this patient and patient #6. Review failed to reveal nursing documentation of the injury i.e., swelling, discoloration, deformity etc. Review revealed a physician order by MD #1 on 04/02/2017 at 0720 for 1:1 at all times (staff remains with patient at all times and documents on the patient safety rounds sheet every 7 minutes) and discontinued 04/03/2017 at 1800 by MD #1. Review of patient safety rounding documentation failed to reveal every 7 minute documentation on 04/02/2017 at 0730 through 04/03/2017 at 1800. Review failed to reveal every 7 minute documentation according to the director of nursing (DON) during the record review. Continued review of orders by MD #3 on 04/02/2017 at 0950 revealed orders for an x-ray of the ® foot, ® hand and arm for pain. Review revealed a radiology report dated 04/02/2017 at 2138 (~ 12 hours, 38 minutes after the MHT note indicating the patient requested ice for his hand and foot) for "SWELLING/PAIN" revealed, " ... RIGHT FOOT ... Findings: No acute fracture ...Small talar (ankle bone) break. ...RIGHT HAND ... Findings: No acute fracture ... Soft tissue swelling is seen. Review failed to reveal nursing documentation of the patient's injuries or of reassessment. Review of a physician's note on 04/02/2107 at 1254 by MD #3 revealed "... (Patient name) was seen today. He is extremely manic, agitated, and grandiose. He was aggressive with a fellow patient because of a conflict between them. ...He is on one-to-one to prevent aggressive behavior at present time.

Review on 05/09/2017 at 1500 of video surveillance of Unit B on 04/02/2017 at approximately 06:53:00 - 07:01:00 with the risk manager (RM) and DON revealed:
- 06:55:29 Patient #11 walked over to patient #6 and attempted to hug him in the dayroom.
- 06:55:30 Patient #6 immediately began backing away. There was a verbal exchange from patient #6 who is shaking his head no, and pointing his finger at patient #11 while holding a cup of coffee in the same hand.
- 06:55:53 The 7a-7p nurse (RN #3) walked onto the unit. Patient #6 walked to the end of the row of chairs and started to walk around but patient #11 began walking down toward him, and patient #6 walked back up the row away from him. Patient #11 walked back up and stood directly in front of him on the opposite side of the chairs. Patient #6 is observed pacing back and forth and holding his arm out at times and up at others. Both continue to verbally engage one another. MHT #1. MHT #1, MHT #2 and RN #3 look in the direction of where patient #6 and #11 are standing.
- 06:56:04 Patient #6 backed up again, shaking his head "No", pacing side-to-side, waving his left arm, finger pointed.
- 06:56:18 Patient #11 walked over and sat down in chair #1, closest to the nursing station and patient #11 stood in front of chair #4 in the row, furthest from the nursing station. Patient #6 was observed with legs crossed, rapidly shaking his foot. The verbal exchange continued. MHT #1, MHT #2, and RN #3 continued to watch the verbal exchange between patient #6 and #11.
- 06:56:37 Patient #11 began dancing in front of #6.
- 06:56:43 Patient #6 got up from the chair, walked over to the nursing station.
- 06:56:51 Patient #6 reached over the counter and picked up a stainless steel coffee dispenser while swinging it at his side. MHT #1 and MHT #2 are observed on the video watching as patient #6 picked the coffee dispenser up. Patient #6 stood at the nursing station briefly, began walking toward Patient #11 and stopped. Patient #11 was observed standing in the dayroom, talking to a peer.
- 06:56:55 MHT #2 observed getting up from a seated position and held her hand out. Patient #6 put the coffee dispenser back on the nursing desk and MHT #2 walked over and moved it from within reach.
- 06:57:01 MHT #1 remained in the same position, leaned over the nursing station counter, looking up periodically in the direction of the dayroom where the patients are observed having verbal exchange.
- 06:57:06 Patient #6 walked directly from the nurse's station and threw coffee, according to staff interview, on/at patient #11.
- 06:57:10 Patient #6 picked up a wooden chair and raised it to his mid-chest area. MHT #1 observed in the same position, leaning over the nursing station desk.
- 06:57:13 Patient #6 put the chair down, after a verbal prompt from RN #3 according to interview. MHT #1 began walking toward the direction of the dayroom and stood at the end of the nursing station counter but did not come around to the side where patient #6 and #11 were located.
- 06:57:18 Patient #6 walked over to #11 and hit him in the stomach, verbal exchange continued. The verbal exchange intensifies with notable change in expression and body language. MHT #1 remains standing at the end of the nursing station and RN #2 is observed at the nursing station, looking at patient #6 and #11. Observation revealed nursing staff did not attempt to physically separate the patients.
- 06:57:21 Patient #6 bent forward and ran toward to #11, striking him in the right thigh with his left shoulder. Patient #11 swung at patient #6 and missed initially. Patient #6 immediately began striking #11. Patient #11 pushed Patient #6 and a physical altercation ensued.
- 06:57:24 The physical patient-to-patient altercation between Patient #6 and Patient #11 continued to escalate. Observation revealed staff did not attempt to physically separate the patients.

Interview on 05/09/2017 at 1545 with the DON revealed documentation for any patient on Level II precautions, regardless of cause, is every 7 minutes. Interview revealed the hospital's observation policy does not specify that every 7 minutes checks are required for Level II precautions but it is the expected protocol. Interview revealed nursing staff are trained to do every 7 minute checks for Level II precautions during orientation and have annual competencies on same. Interview revealed patient #6 was placed on Level II observation upon return from the ED on 04/02/2017 at 1200 for safety. During review of the medical record, the DON confirmed staff failed to document on the safety rounds sheet every 7 minutes. Not really sure how to incorporate this. There was no MD order for 1:1 but DON insists patient was maintained on 1:1.

Interview on 05/10/2017 at 0905 with RN #1 (7p-7a nurse) with the DON present, revealed 16 years of nursing experience, including 6 years of psychiatric nursing. Interview revealed nursing staff received Crisis Prevention Intervention (CPI) training on orientation and annually thereafter. Interview revealed de-escalation techniques and skills are taught during the training. Interview revealed staff are taught early intervention is the key to successful de-escalation. Interview revealed as soon as the patient begins to show symptoms such as "yelling, being loud, pacing, crying" staff should "be with the patient immediately" and call a Code White emergency. Interview revealed when a patient attempts to harm themselves or someone else, Code White is called using "walkie-talkies" and overhead page. Interview revealed, "If I had a Code White, I would be the team lead. Interview revealed RN #1 was in the back of the nursing station, waiting to give shift report, and could not hear the altercation between patient #6 and patient #11. Interview revealed RN #2 attempted to call a Code White via his "walkie-talkie" but it did not transmit clearly. Interview revealed RN #1 paged Code White overhead. Interview revealed, "I think we did our best" with the situation. "I think they (MHT #1 and MHT #2) should have done better." Interview revealed RN #1 did not document circumstances surrounding the patient-to-patient altercation between patient #6 and patient #11 or complete an assessment following same. Interview revealed, RN #1 did not report details of the episode to RN #3, the oncoming nurse because she was "not aware" of what transpired. Interview revealed RN #1 thought MHT #1 and MHT #2 should have attempted de-escalation techniques to diffuse the escalating behaviors between patient #6 and patient #11.

Interview on 05/10/2017 at 1120 with MHT #3 during tour of Unit B revealed a history of 9 years of psychiatric experience. Interview revealed staff are trained to move patients away from the agitating factor or to remove it, if possible. Interview revealed staff are trained to intervene early, at the first sign of patient-to-patient altercation before the situation escalates and get out of hand.

Interview on 05/10/2017 at 1240 with the patient advocate revealed she received a call and was asked to talk with patient #6 and had a face-to-face conversation with him "sometime that same week" (week of altercation). Interview revealed patient #6 felt the incident "could have been avoided" if staff had acting more quickly. Interview revealed patient #6 stated he "wished they would have broken it up faster, was upset because he got hurt and wanted to know if we would pay for his medical bills." Interview revealed the advocate's concerns following her investigation were staff's "response time". Interview revealed she questioned what alternates were provided to avoid patient-to-patient altercation, timeliness of staff intervention, de-escalation attempts. "What did we do? Did we stand around too long?"

Interview on 05/10/2017 at 1310 with RN #3 (7a-7p nurse) with the DON present, revealed when she walked onto the unit she remembered thinking it was early for patient #6 and patient #11 to be "talking as they were". Interview revealed she stopped as asked MHT #1 what was going on but could not recall what he said. Interview revealed she entered the nursing station, sat her "stuff" down and walked around the reporting section where RN#1 and RN #2 were sitting, waiting to give report. Interview revealed she asked what was going on and both RN #1 and RN #2 said the two were out there having a conversation. Interview revealed RN #3 she walked out into the open area of the nursing station "because it seemed like more than just a conversation." Interview revealed RN #3 believed the situation was "escalating" by the tones of their voices. Interview revealed RN #3 "was gonna go ahead and do report but things started to happen. MHTs were coming in for first shift. (Patient #6 name) picked up a chair and I said, 'No, No, No, you can't do that'. (RN #1 name) went to the phone and called a Code White." Interview revealed a Code White is called when additional staff are needed to maintain a safe environment and that all efforts are made to get those involved "away from each other". Interview revealed RN #3 opened the door into the dayroom, stepped out and prompted patient #11 to calm down and to stop his behavior. Interview revealed other nurses form the Code White team were assisting patient #6 with his injuries and she returned to the nursing office to call the physician and to being the transfer documentation. Interview revealed RN #3 had MHT #1 write a statement about the occurrence and wrote progress notes dated 04/02/2017 at 1035 for patient #6 and patient #11. Interview revealed she could not recall whether she received report from the 7p-7a nurses regarding circumstances surrounding the patient-to-patient altercation. Interview confirmed escalating behaviors were noted as she walked through the unit to the nursing station.

Interview on 05/10/2017 at 1415 with the nurse manager revealed he received report from the night supervisor but did not understand the sequence of events and how the altercation escalated. Interview revealed he called RN #3 (7a-7p nurse) but still not know how the situation escalated in the manner that it did. Interview revealed he called RN #2 (7p-7a nurse) to determine what happened prior to first shift nursing staff coming onto the floor and activation of the Code White. Interview revealed RN #2 stated they (RN #1 and RN #2) were "back in the nursing station getting report" and could not tell him how the escalation progressed. Interview revealed he did not speak with RN #1. The DON requested that the nurse manager follow up with RN #2 and she would follow up with RN #1. Interview revealed the DON "called people in to discuss what happened. Interview revealed, "Ultimately it is nursing's responsibility to watch the patients. Interview revealed the nurse manager watched the video surveillance and thought "they (nursing staff) took a little too long" to respond to the escalating behaviors. Interview revealed being "pro-active is key. We teach and tell people when to step in." Interview revealed, "I wondered where they were. I think (MHT #1 name) was shocked and scared." Interview revealed "verbal de-escalation is the first line of defense". Interview confirmed nursing staff failed to intervene when patient #6 and patient #11 began to escalate.

Interview on 05/10/2017 at 1445 with MHT #4 and the human resource director (HR) revealed both are trained CPI instructors. Interview revealed that when patients began "arguing" staff should "intervene immediately, separate and talk to them." Interview revealed both CPI trainers watched video surveillance and followed up with MHT #1 and MHT #2. MHT #2 reported she told patient #6 to instructed (patient #6 name) "to put the chair down", resulting in a "missed opportunity" to implement de-escalation techniques to diffuse the situation. The HR stated staff are taught to "get between them (patients). Our job is to ensure patient safely." Interview revealed MHT #1 was retrained on de-escalation techniques according to CPI. MHT #4 stated in his "opinion, (MHT #1 name) was afraid of (patient #11 name) but I told him he has to get help." Interview revealed MHT #1 was the only employee who received additional CPI training following the patient-to-patient altercation. Interview confirmed nursing staff failed to intervene when patient #6 and patient #11 began to escalate.

Interview on 05/10/2017 at approximately 1500 with the DON revealed the focus of administrative was with the MHT's failure to respond to the escalating situation "because they (MHT #1 and MHT #2) were present." Interview revealed there was no additional training for the nurses (RN #1 and RN #2). Interview revealed plans to conduct a "case study" using the patient-to-patient altercation between patient #6 and patient #11. Interview revealed as part of the review, nursing staff will be reminded that they "can't wait until the situation escalates. I think they (RN #1 and RN #2) got so caught up in report" and were not aware of the increasing aggressive behavior in the dayroom.

Interview on 05/10/2017 at approximately 1500 with the DON revealed nursing staff are taught "to respond to anything. We're here to take care of patients." Interview revealed, "No retraining (for nurses) was indicated at the time" during or following the investigation. Interview revealed MHT #1 received additional CPI training.

Interview on 05/11/2017 at 0930 with RN #4 revealed an overhead page was made indicating the need for additional staff support (Code White). Interview revealed he was unable to recall whether 7p-7a staff were on the hall. Interview revealed his focus was assessing the situation and determining which patient needed the most medical attention. Interview revealed he spoke with patient #11, confirmed on the video surveillance, and then went to assess nurse responsible for the patient(s).

3. Medical record review on 05/09/2017 for Patient #5 revealed a 20 year-old was admitted to the facility on 03/25/2017 with complaints of suicidal ideation. Review revealed a diagnosis of bipolar disorder, Opioid use disorder, cocaine use disorder, and history of suicidal ideation. Review of physician orders by MD #3 on 03/25/2017 at 0800 revealed Level II observation (every 7 minute documentation), fall and suicide precautions were ordered. Review of patient safety rounds documentation revealed documentation every 15 minutes on 03/25/2017 0645-2345. Review failed to reveal every 7 minute documentation as outlined in hospital policy and according to the director of nursing (DON) during the record review.

Interview on 05/09/2017 at 1545 with the DON revealed documentation for any patient on Level II precautions, regardless of cause, is every 7 minutes and are done more frequently "for safety". During review of the medical record, the DON confirmed staff failed to document on the patient safety round flow sheet every 7 minutes.