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Based on interview and record review, the facility failed to ensure that 2 (Patients #10 and #11) of 14 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and Patient #14) received their psychiatric treatment in a safe setting, as evidenced by Patient #11 physically assaulting Patient #10 thus putting both patients at risk for harm.

TX00246413

Findings included:

Record review of the Complaint by Patient #10 dated 06/15/2016 at 1222 revealed she was wrongfully sent to PICU and was then physically assaulted by a patient shortly upon arrival.

Record review of the Psychiatric Evaluation by Personnel #56 (MD) dated 05/12/2016 at 1752 revealed a 50-year-old-female admitted on 05/11/2016 with suicidal ideation due to being "sleep deprived."

Record review of Physician Admission Order by Personnel #59 (MD) dated 05/11/2016 at 1610 revealed admission into PICU. Unit restriction and suicide and elopement precautions were ordered.

In an interview with Personnel #53 (QM) on 11/15/2016 at 0915, she stated Patient #10 was attacked from behind by Patient #11. She also stated the attack was unprovoked.

Record review of the Physician Orders by Personnel #56 (MD) dated 05/11/2016 at 1903 revealed an order to transfer Patient #10 to any unit where there was an available bed.

Record review of RN Narrative by Personnel #60 (RN) dated 05/11/2016 at 1930 revealed Patient #10 was transferred from Psychiatric Intensive Care Unit (Unit 1).

Record review of policy AIM 105, Admission Services, dated 06/2015 revealed: "Patient unit ... shall be made on the basis of ... The needs of the patient ... The needs of other patients on a unit ... The attending physician's request or approval ... Space available. Patients may be admitted to a unit and transferred to another unit based upon the patient's needs and other patient's needs."