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Based on observations, staff interviews, and record review it was determined that the hospital: (1) failed to protect and prevent abuse of 3 (#2, #21 and #22) of 23 patients who were located in the Behavioral Health Unit. Patient #2 and Patient #21 were physically assaulted. These incidents resulted in Immediate Jeopardy on 9/11/14 and were ongoing at the time of exit on 10/1/14.

The Findings Include:

Refer to A142 for the facility's failure to ensure the safety and privacy of 23 patients located on the Behavioral Health Unit, which resulted in severe physical injury to Patient #2.

Refer to A144 for the facility's failure to provide a safe environment for 23 vulnerable patients on the Behavioral Health Unit, which resulted in severe physical injury to Patient #2.

Refer to A145 for the facility's failure to protect and prevent abuse to 2 (#2 and Patient #21) of 23 patients, which resulted in severe physical injury to Patient #2.

Based on observations on the Behavioral Unit, video observations, patient and staff interviews, and record reviews, the facility failed to ensure the safety and privacy of 23 patients located on the Behavioral Health Uni, which resulted in severe physical injury to Patient #2. This occurrence resulted in Immediate Jeopardy on 9/11/14 and was ongoing at the time of exit on 10/1/14.

The Findings Include:

A medical record review for Patient #2 revealed she was admitted into the facility on 9/8/14 under Baker Act by law enforcement on 9/8/2014. She was stabilized in the Emergency Department. Patient #2 was deemed medically cleared and transported to the Behavioral Health Unit (BHU) on 9/9/2014. A medical record review of Patient #2's current admission revealed she was admitted into the facility on 9/28/2014 with a complaint of seizures. She was treated for a recent head injury secondary to trauma. Patient #2 returned to the facility and was treated for a wound infection and skin graft. A review of the History and Physical dated 9/28/2014 revealed Patient #2 was alert and oriented.

An interview with Patient #2 on 9/29/2014 at 7:36 pm revealed she was alert and oriented to person, place, and time. Patient #2 was asked if she felt safe in the facility; she responded by saying, "Yes and No; When I was Baker Acted, I came in because I overdosed. I did my full 72- hour admission. There was one gentleman that came in the day before I was supposed to leave (discharged)." The man was named as Patient #1. We (the patients) could tell that he had some aggression issues." The patients were all in the multi-purpose room after playing Bingo. There was another patient (Patient #21) who was on a phone call. Patient #1 walked up to him and grabbed the phone and at least two smacks of the phone could be heard in the room due to Patient #21 being hit. Patient #21 walked away and Patient #1 stayed in the multi-purpose room. One of the nurses (Employee D) opened the medication room door and said, "You cannot hit people here." Patient #2 remembered Patient #1 apologizing for it. Patient #1 went out of the multi-purpose room to watch television. Patient #2 said she fell asleep at about 2:00 am. Patient #1 was still in the hallway pacing up and down. The staff had locked the hallway wings on both sides so that patients could be on one side of the wing or the other. Patient #2 stated she heard the night-time crew tell him "You cannot be out here; you have to go to your room." She said nobody reinforced it. Patient #2 said she eventually got up to go to the bathroom. "I think the only reason he had stopped at my room was because he heard my toilet flush. I walked out of my bathroom and saw Patient #1 standing there. He was not looking into my window. He was looking down the hallway. I went back to sleep and later that morning, I heard my door open. Patient #1 was very violent; there were no words in the yelling. He was just yelling. I don't remember if he kicked or pushed me down to the floor. He pulled my hands underneath his buttocks, sitting on me so I could not fight back. He was yelling and screaming. I remembered taking two shots to the face. Then I remember him picking me up by the throat, picking my head up and bashing it into the ground. It was at this point that I blacked out."

An interview with the Risk Manager on 9/29/14 at 6:32 pm revealed that during her investigation of the attack of Patient #2, Patient #1 was observed by the Social Worker in an elderly female patient's room, touching her arm. Prior to the attack of Patient #2, Patient #1 was easily redirected and apologized. On 9/29/14 at 8:30 pm, the Risk Manager denied knowledge of Patient #1 hitting another patient with a phone while on the BHU. The Risk Manager stated the surveillance video has been reviewed thoroughly by several different agencies and this is the first she has heard about Patient #1 hitting another patient. When asked by this surveyor what has the facility done to ensure that an incident like this does not occur again in the future, the Risk Manager responded "Nothing." The Chief Nursing Officer (CNO) spoke up and stated since this incident happened, the facility has been looking at issues such as staffing, to include a male on each shift, adjusting the cameras, and the facility has an onsite uniformed Sheriff 's Officer 24/7; facility security is already in place, but they are making an increased number of rounds.

An observation of the BHU on 9/29/2014 at 8:45 pm with the CNO, Risk Manager, Director of the BHU, and the Director of Quality revealed that while watching the surveillance monitor in the nurses' station, three adults standing side by side inside of the Seclusion Room doorway could not be visualized on the monitor. The Seclusion Room was unlocked upon arrival to the unit. Upon exiting the BHU Unit on 9/29/2014 at 9:50 pm, the Seclusion Room remained unlocked and available to patients for use.

An interview with the BHU Director on 9/29/2014 at 8:55 pm revealed that she and the facility has been aware of the blind spot in the viewing of the Seclusion Room since 9/11/14, when the surveillance tapes were reviewed, and are currently looking into solutions for eliminating the blind spot. The BHU Director stated the Seclusion Room remains open for the use of patients day and night.

An interview with the Security Director on 9/30/14 at 12:10 pm, while reviewing the surveillance video from 9/11/14, revealed that he tracked Patient #1 on the surveillance video from the Emergency Department (ED) to his arrival on the unit starting on 9/10/2014 at 4:01 pm, and the BHU from the time Patient #1 arrived into the facility until the incident on 9/11/14 at 3:24 am. The Security Director stated there was no evidence to show that Patient #1 was aggressive or that the attack could have been predicted. The Security Director was asked by the surveyor about any other incidents involving Patient #1; he stated,"They (other patients) reported that Patient #1 grabbed a phone from another patient to the deputies and their statements were submitted to the Sheriff 's office."

An observation of the BHU surveillance video on 9/30/2014 at 12:10 pm revealed on 9/10/2014 at 7:59 pm, that Patient #21 is observed on the telephone located on the right side on the video frame; Patient #1 approached Patient #21 in an aggressive manner. Patient #21 is observed holding the phone and pointing at Patient #1. Patient #1then hit Patient #21 and pushed him into the phone and a weight scale. Patient #1 then pushed the door to the multi-purpose room closed. Patient #21, who was on the phone, walked away and Employee D (identified by the Security Director) opened the medication room door looking toward Patient #1. Patient #1 walked to the medication room door and spoke to Employee D. Patient #2 is observed at the table participating in an activity at this time. The video observation was confirmed by the Security Director, who was controlling the video speed and rewinding at the request of the surveyors. Further observation of the BHU surveillance video with a date time stamp of 9/11/14, between the hours of 12:00 am - 4:00 am, revealed Patient #1ambulating down the hallway on the south side of the care area, back and forth. He is observed entering and exiting multiple patient rooms multiple times, over several hours. Unit staff is observed passing Patient #1 in the hallways multiple times.

At 2:35 am, Patient #1 can be seen entering the Seclusion Room where Patient #2 is observed sleeping (based on the hallway surveillance video). The Seclusion Room video reveals an increase in the lighting at the entrance to the Seclusion Room. Patient #1 cannot be seen entering the Seclusion Room due to a significant-sized blind spot on the video surveillance. The Seclusion Room light is turned on by Patient #1. Patient #2 is observed sleeping from the Seclusion Room surveillance video. Patient #2 woke up and walked toward the Seclusion Room door at 2:36 am. The Seclusion Room door is open and a shadow is present. After Patient #2 approached the door area, only an image of human feet shaking were seen at the edge of the camera shot. The hallway surveillance video revealed 2 staff members exiting the nurse's station to the Seclusion Room.

At 2:38 am, Patient #1 exited the Seclusion Room and forced himself into the nurses' station behind 2 staff members (who were identified by the Security Director as nurses). The staff nurses are observed exiting the nurses' station. A male staff member is observed entering the BHU and standing near the nurses' station door and in front of the window, blocking visual access to the Seclusion Room. The 2 nurses can be seen on the surveillance video walking back and forth in the hallway. The simultaneous observation of 2 camera shots revealed Patient #2 lying on the floor, motionless, without staff intervention until 2:40 am, when the ED staff (identified by the Security Director) arrived to the BHU.

At 2:40 am, Patient #2 can be seen in the Seclusion Room video moving around while lying on the floor.

A medical record review of Patient #1 revealed he was escorted into the Emergency Department (ED) by his father on 9/8/14 at 6:21 pm with a complaint of bizarre behavior for three days. Patient #1 reported that he "hears whispers, but is unable to decipher what they are saying" (auditory hallucinations). A review of the emergency provider notes dated 9/9/2014 revealed reports that Patient #1 was at the gym on 9/8/2014 and called someone the Devil and stated that he was God. The family of Patient #1 reported that Patient #1 believed he controlled the weather; is having an internal conflict himself and feels he has powers. The family also reported a prior episode of bizarre behavior several months earlier, after Patient #1 lost his job. The ED physician's assessment revealed Patient #1 was alert and oriented to person, place, and time. The plan for treatment revealed Patient #1 was to be medically cleared for a psychiatric evaluation after blood samples for a blood chemistry and urine toxicology were sent and resulted. The ED physician's plan is to have Behavioral Health evaluate Patient #1 and assist with the disposition.

A review of the Psychiatric Assessment dated 9/9/2014 at 8:03 pm revealed Patient #1 was an involuntary Baker Act patient.

Patient #1 was admitted onto the Behavioral Health Unit on 9/10/2014 at 2:45 pm. The nursing notes dated 9/10/2014 at 8:14 pm revealed that Patient #1 was admitted to the unit with standing physician's orders. He was cooperative with the admission process and signed for his medications/treatment. Patient #1 was oriented to the unit, and was advised to call his family using the access code. Their additional nursing notes stated, 'will continue to monitor Patient #1 for safety and encourage coping skills'.

At 2:35 am on 9/11/14, the nursing notes revealed Patient #1 had been up and about early in the shift. He was medicated with Vistaril, Zyprexa and Ambien at bedtime. Patient #1 lay down for a few hours and was then observed up and walking the hallways.

At approximately 2:23 am, yelling was heard from the Quiet Room. Patient #1 was observed punching Patient #2 in the head repeatedly. The nurse yelled at Patient #1 to stop and placed a hand on his shoulder, but Patient #1 continued hitting Patient #2. Patient #1 had a strange, angry look on his face. A Code Grey was called. The house supervisor, security, and the police responded. Patient #1 followed the nursing staff into the nursing station prior to the response of facility staff to the Code Grey. He was unreasonable and yelled at the nursing staff to get out. Patient #1 was restrained by the police in the nursing station. The physician was notified and stated the police could take Patient #1 into custody. Patient #1 left the nursing unit with police in a wheelchair. The review of the nursing notes does not mention or support the video surveillance of Patient #1 attacking Patient #21 while in the multi-purpose room on 9/10/2014 at 7:59 pm; nor do the nursing notes mention or give account of the report of Patient #1 entering an unknown patient's room multiple times and touching her. There was no documentation in the medical record to support evidence that Patient #1 was re-assessed for increasing violent behaviors and insomnia.

An interview with the Chief Nursing Officer on 9/29/14 at 10:00 pm revealed that she has reviewed the video of Patient #1 during his time in the BHU, and did not recall seeing any signs of aggression toward other patients or staff.

An interview with Employee A on 10/1/2014 at 8:31 am revealed patient behaviors are documented in the medical record under Patient Goals. If patients are observed with aggressive behaviors, then they are documented in patient notes. Patient behaviors are documented once a shift, but if something happens, then an additional entry is made as soon as possible after the incident. The behavioral staff complete safety rounds every 15 minutes on both day and night shifts. Additionally, there is a surveillance video monitor located in the nursing station. Usually the charge nurse will sit at the computer near the monitor and is responsible for observing the monitor throughout the shift. On the early morning of 9/11/14, Patient #1 was observed pacing the hallways prior to attacking Patient #2. "Patient #1 was not my assigned patient; my assignment was on the other side of the hallway. I did not hear Patient #1 say anything. I realized there was a problem when I heard Patient #2 yelling 'help me'. At that time, all three staff members were in the nurses' station and the Behavioral Health Coordinator was at her dinner break. I jumped up, secured the nursing station by locking both the top and bottom of the door on the far side, the medication room door on the top and bottom, and then I started out of the door and the other nurse yelled 'Call a Code Grey". I grabbed the radio so that I could keep moving toward the situation to help. I really did not know what was going on. I opened the door and saw Patient #1 hitting Patient #2 with his fist. I yelled at him by name and said 'Stop'; he looked at me, hit Patient #2 one more time and then he stood up and walked toward me. The next thing I remember is being in the nurses' station. We could not get the door shut fast enough. Patient #1 had his fist up like he was going to hit me. Patient #1 told the other nurse and me to get out. The PCT unlocked the other door and left out of the other side of the nurses' station. The other nurse and I left out of the door we entered through. We then stood at the door to try to make sure Patient #1 did not get out. Patient #2 could still be heard yelling, 'help me, help me'. The House Supervisor responded to the unit and began talking to Patient #1 through the window of the nurses' station. He called for a Rapid Response Team. The other nurse and I went into the room and tried to help Patient #2. Patient #2 was given a towel to wrap her head. She was still lying down on her side. Patient #2 was not observed unconscious at any time."

An interview with Employee B on 10/1/2014 at 9:00 am revealed on 9/10/14, Patient #1 was observed fine and interacting well with the other patients. "I heard from other staff that night that Patient #1 got into it with another patient but I don't know, because I was not there; it was just something I heard. I also heard something about him going into another patient's room but she always stayed in her room." On the morning of 9/11/14, Patient #1 was observed pacing and standing at the end of the hallway. He was looking out the door. Employee B stated she asked him if he was OK and he would nod, so, "I did not think anything of it." Employee B stated that she does not usually look at the monitors, because she sees the patients while doing the rounds. "I realized there was a problem when I heard an emergency light alarm and the door shut to the Seclusion Room, and then I heard a scream. We began heading that way, and when I got into the room, I saw him straddled over Patient #2, hitting her. I went to call security and I was told that someone had already called, but I did not go back into the room. I waited for security, then I tried to keep the patients in their rooms and tend to them." Employee B stated if patients are observed going into another patients' rooms, then staff will try to stop them and redirect them immediately, then she would let the nurse know. Employee B denied observing Patient #1 going into any other patient's room; however, "He was observed standing in the hallways at the corner, and it made me feel uncomfortable."

An interview with Employee C on 10/1/2014 at 10:37 am revealed that she remembered a patient reporting to her that a doctor kept coming into her room and putting his hand on her arm. That patient was Patient #1 by name, and said that he was in Room 241. That particular patient was assigned to 243. Employee C said, "I went into the nurses' station and told the Charge Nurse. I ask him if he had been in to see the patient in Room 243. I informed him that the Patient in 243 was named Patient #1 by name, and complained that he keeps coming into her room, and he said 'OK'.

An interview with BHU Director on 10/1/14 at 9:31am revealed that one of the charge nurse duties is to sit at the desk and watch the monitor. Both nurses are responsible for the daily duties, but just one is considered in charge. The BHU does not have a dedicated staff member assigned to watch the monitor. The charge nurse is expected to observe the monitor while she is documenting; if she has to get up for anything, then the other nurse or tech is responsible for watching the monitor. The Unit allows for additional staff during shift change, to ensure the monitor is watched and that all patients are cared for. The facility does not have a policy directly related to staff monitoring of the surveillance. When shift change arrives, Patient Care Technicians and Nurses exchange information on behaviors and special interventions. If the patient is on every 2 hour checks, they write it down and pass it on to the next shift.

At 10/1/2014 at 10:43 am, the Behavioral Health Director revealed that the charge nurse for the day was questioned, and he said that he went to Patient #1 and explained that he was not allowed to go into other patients' rooms. She stated the Charge Nurse reported that Patient #1 apologized. It is the expectation of the facility that anything that happens outside of the normal operations should be documented and charted in the medical record.

If the staff is made to feel uncomfortable by a patient's presence, or if there is a patient showing unusual behavior, the unit is to immediately report the behaviors to the charge or the attending nurse. The charge nurse should investigate the situation, and determine if further action is warranted. Increased supervision is determined based on the charge nurse's judgment. The facility has a protocol that patients can be offered other medications. If the patients are presenting a danger to themselves or others, then the situation is escalated to include one-to-one seclusion or restraints if warranted.

If patients complain that they cannot sleep due to snoring patients or other disruptive patients and request to go into the Seclusion Room to sleep, they are allowed.

A review of the Patient Rights and Responsibilities Policy and Procedures, with an effective date of 12/16/2013 revealed, "A patient has the right to receive care in a safe setting."

A review of the Abuse Assessment Policy and Procedures, with an effective date of 1/16/2014, revealed the patient has the right to be free from neglect and exploitation, and verbal, mental, physical, and sexual abuse, while in the care of Orange Park Medical Center.
1. Patients will be protected from abuse while the patient is receiving care, treatment, and services.
2. The hospital will evaluate all allegations, observations, and suspected cases of abuse.

A review of the Patient Assessment/Reassessment Policy and Procedures, with an effective date of 1/16/2014, revealed patient reassessments are based on, but are not limited to, changes in condition, patient care needs, or problem identification, and response to a treatment/ intervention. Patients are reassessed every shift, with a change in condition, change in RN, and as needed.

Based on video observations, patient and staff interviews, and record reviews, the facility failed to provide a safe environment for 23 vulnerable patients in the Behavioral Health Unit, which resulted in severe physical injury to Patient #2. This occurrence resulted in Immediate Jeopardy on 9/11/14 and was ongoing at the time of exit on 10/1/14.

The Findings Include:

A review of the complaint revealed the screams coming from a nearby room will be practically impossible to forget. An unidentified woman was visibly shaken after what she heard early Thursday morning. "I would never forget that sound. It was blood curdling"; she said, "I just keep thinking about her. Since there was so much blood, I can't begin to imagine the kind of injuries. I had no idea that could've happened in a hospital."

A medical record review for Patient #2 revealed she was admitted into the facility on 9/8/14 under a law enforcement Baker Act on 9/8/2014. She was stabilized in the Emergency Department. Patient #2 was deemed medically cleared and transported to the Behavioral Health Unit (BHU) on 9/9/2014. A medical record review of Patient #2's current admission revealed she was admitted into the facility on 9/28/2014. She was treated for a recent head injury secondary to trauma. Patient #2 returned to the facility and was treated for a wound infection and skin graft. A review of the History and Physical dated 9/28/2014 revealed Patient #2 was alert and oriented.

An interview with Patient #2 on 9/29/2014 at 7:36 pm revealed she was alert and oriented to person, place and time. Patient #2 was asked if she felt safe in the facility and she responded by saying, "Yes and No. When I was Baker Acted, I came in because I overdosed. I did my full 72- hour admission. There was one gentleman that came in the day before I was supposed to leave (discharged)." The man was named as Patient #1. "We (the patients) could tell that he had some aggression issues." The patients were all in the multi-purpose room after playing Bingo. There was another patient (Patient #21) who was on a phone call. Patient #1 walked up to him and grabbed the phone and at least two smacks of the phone could be heard in the room due to Patient #21 being hit. Patient #21 walked away and Patient #1 stayed in the multi-purpose room. One of the nurses (Employee D) opened the medication room door and stated, "You cannot hit people here." Patient #2 remembered Patient #1 apologizing for it. Patient #1 went out of the multi-purpose room to watch television. Patient #2 stated she fell asleep at about 2:00 am. Patient #1 was still in the hallway pacing up and down. The staff had locked the hallway wings on both sides so that patients could be on one side of the wing or the other. Patient #2 stated she heard the nighttime crew tell him that, "You cannot be out here; you have to go to your room." She said nobody reinforced it. Patient #2 stated she eventually got up to go to the bathroom. "I think the only reason he had stopped at my room was because he heard my toilet flush. I walked out of my bathroom and saw Patient #1 standing there. He was not looking into my window. He was looking down the hallway. I went back to sleep and later that morning I heard my door open. Patient #1 was very violent; there were no words in the yelling. He was just yelling. I don't remember if he kicked or pushed me down to the floor. He pulled my hands underneath his buttocks sitting on me so I could not fight back. He was yelling and screaming. I remember taking two shots to the face. Then I remember him picking me up by the throat, picking my head up and bashing it into the ground. It was at this point that I blacked out."

An interview with the Risk Manager on 9/29/14 at 6:32 pm revealed that during her investigation of the attack of Patient #2, Patient #1 was observed by the Social Worker in an elderly female patient's room, touching her arm. Prior to the attack of Patient #2, Patient #1 was easily redirected and apologized. On 9/29/14 at 8:30 pm, the Risk Manager denied knowledge of Patient #1 hitting another patient with a phone while on the BHU. The Risk Manager stated the surveillance video has been reviewed thoroughly by several different agencies and this is the first she has heard about Patient #1 hitting another patient. When asked by this surveyor what has the facility done to ensure that an incident like this did not occur again in the future, the Risk Manager Responded, "Nothing." The CNO spoke up and stated, since this incident happened, the facility has been looking at issues such as staffing, to include a male on each shift adjusting the cameras, and the facility has an onsite uniformed Sheriff 's Officer 24/7; facility security is already in place, but they are making an increased number of rounds.

An observation of the BHU on 9/29/2014 at 8:45 pm with the CNO, Risk Manager, Director of the BHU, and the Director of Quality revealed that while watching the surveillance monitor in the nursing station, three adults standing side by side inside of the Seclusion Room doorway could not be visualized on the monitor. The Seclusion Room was unlocked upon arrival to the unit. Upon exiting the BHU unit on 9/29/2014 at 9:50 pm the Seclusion Room remained unlocked and available to patients for use.

An interview with the BHU Director on 9/29/2014 at 8:55 pm revealed that she and the facility has been aware of the blind spot in the viewing of the Seclusion Room since 9/11/14, when the surveillance tapes were reviewed and are currently looking into solutions for eliminating the blind spot. The BHU Director stated the Seclusion Room remains open for the use of patients throughout both the day and night.

An interview with the Security Director on 9/30/14 at 12:10 pm, while reviewing the surveillance video from 9/11/14, revealed that he tracked Patient #1 on the surveillance video from the Emergency Department (ED) to his arrival on the unit starting on 9/10/2014 at 4:01 pm, and the BHU from the time Patient #1 arrived into the facility until the incident on 9/11/14 at 3:24 am. The Security Director stated there was no evidence to show that Patient #1 was aggressive or that the attack could have been predicted. The Security Director was asked by the surveyor about any other incidents involving Patient #1; he stated, "They (other patients) reported that Patient #1 grabbed a phone from another patient to the deputies and their statements were submitted to the Sheriff 's office."

An observation of the BHU surveillance video on 9/30/2014 at 12:10 pm revealed on 9/10/2014 at 7:59 pm, that Patient #21 is observed on the telephone located on the right side of the video frame; Patient #1 approached Patient #21 in an aggressive manner. Patient #21 is observed holding the phone and pointing at Patient #1. Patient #1 then hit Patient #21 and pushed him into the phone and a weight scale. Patient #1 then pushed the door to the multi-purpose room closed. Patient #21, who was on phone, walked away and Employee D (identified by the Security Director) opened the medication room door looking toward Patient #1. Patient #1 walked to the medication room door and spoke to Employee D. Patient #2 is observed at the table participating in an activity at this time. The video observation was confirmed by the Security Director, who was controlling the video speed and rewinding at the request of the surveyors. Further observation of the BHU surveillance video with a date time stamp of 9/11/14 between the hours of 12:00 am - 4:00 am revealed Patient #1 walking down the hallway on the south side of the care area back and forth. He is observed entering and exiting multiple patient rooms, multiple times over several hours. Unit staff is observed passing Patient #1 in the hallways multiple times.

At 2:35 am, Patient #1 can be seen entering the Seclusion Room where Patient #2 is observed sleeping (based on the hallway surveillance video). The Seclusion Room video revealed an increase in the lighting at the entrance to the Seclusion Room. Patient #1 cannot be seen entering the Seclusion Room due to a significant-sized blind spot on the video surveillance. The Seclusion Room light is turned on by Patient #1. Patient #2 is observed from the Seclusion Room surveillance video, sleeping. Patient #2 woke up and walked toward the Seclusion Room door at 2:36 am. The Seclusion Room door is open and a shadow is present. After Patient #2 approached the door area, only an image of human feet shaking were seen at the edge of the camera shot. The hallway surveillance video revealed 2 staff members exiting the nurse's station to the Seclusion Room.

At 2:38 am Patient #1 exited the Seclusion Room and forced himself into the nurses' station behind 2 staff members (who were identified by the Security Director as nurses). The staff nurses are observed exiting the nurses' station. A male staff member is observed entering the BHU and standing near the nurses' station door and in front of the window, blocking visual access to the Seclusion Room. The 2 nurses can be seen on the surveillance video walking back and forth in the hallway. The simultaneous observation of 2 camera shots revealed Patient #2 was lying on the floor motionless, on the floor without staff intervention until 2:40 am when the ED staff (identified by the Security Director) arrived to the BHU. At 2:40 am, Patient #2 can be seen in the Seclusion Room video moving around while lying on the floor.

A medical record review for Patient #1 revealed he was walked into the Emergency Department (ED) by his father on 9/8/14 at 6:21 pm with a complaint of bizarre behavior for three days. Patient #1 reported that he "hears whispers, but is unable to decipher what they are saying" (auditory hallucinations). A review of the emergency provider notes dated 9/9/2014 revealed reports that Patient #1 was at the gym on 9/8/2014 and called someone the Devil and stated that he was God. The family of Patient #1 reported that Patient #1 believed he controlled the weather; was having an internal conflict himself and felt he had powers. The family also reported a prior episode of bizarre behavior several months earlier after Patient #1 lost his job. The ED physician's assessment revealed Patient #1 was alert and oriented to person, place, and time. The plan for treatment revealed Patient #1 was to be medically cleared for a psychiatric evaluation after blood samples for a blood chemistry and urine toxicology were sent and resulted. The ED physician's impression is psychosis, Baker Act/medical clearance and flight of ideas. The ED physician's plan is to have Behavioral Health evaluate Patient #1 and assist with the disposition.

A review of the Psychiatric Assessment dated 9/9/2014 at 8:03 pm revealed Patient #1 was an involuntary Baker Act patient.

Patient #1 was admitted onto the Behavioral Health Unit on 9/10/2014 at 2:45 pm. The nursing notes dated 9/10/2014 at 8:14 pm revealed that Patient #1 was admitted to the unit with standing physician orders. He was cooperative with the admission process and signed for his medications/treatment. Patient #1 was oriented to the unit, and was advised to call his family using the access code. Their additional nursing notes stated, 'Will continue to monitor Patient #1 for safety and encourage coping skills'.

At 2:35 am on 9/11/14, the nursing notes revealed Patient #1 had been up and about early in the shift. Patient #1 lay down for a few hours and was then observed up and walking the hallways. At approximately 2:23 am, yelling was heard from the Quiet Room. Patient #1 was observed punching Patient #2 in the head repeatedly. The nurse yelled at Patient #1 to stop and placed a hand on his shoulder, but Patient #1 continued hitting Patient #2. Patient #1 had a strange, angry look on his face. A Code Grey was called. The house supervisor, security, and the police responded. Patient #1 followed the nursing staff into the nursing station prior to the response of facility staff, to the Code Grey. He was unreasonable and yelled at the nursing staff to get out. Patient #1 was restrained by the police in the nursing station. The physician was notified and stated the police could take Patient #1 into custody. Patient #1 left the nursing unit with police in a wheelchair. The review of the nursing notes did not mention or support the video surveillance of Patient #1 attacking Patient #21 while in the multi-purpose room on 9/10/2014 at 7:59 pm, nor do the nursing notes mention or give account of the report of Patient #1 entering an unknown patient's room multiple times and touching her. There was no documentation in the medical record to support evidence that Patient #1 was reassessed for increasing violent behaviors and insomnia.

An interview with Employee A on 10/1/2014 at 8:31am revealed patient behaviors are documented in the medical record under 'Patient Goals'. If patients are observed with aggressive behaviors, then they are documented in patient notes. Patient behaviors are documented once a shift, but if something happens, then an additional entry is made as soon as possible after the incident. The behavioral staff complete safety rounds every 15 minutes on both day and night shifts. Additionally, there is a surveillance video monitor located in the nurses' station. Usually, the Charge Nurse will sit at computer near the monitor and is responsible for observing the monitor throughout the shift. On the early morning of 9/11/14, Patient #1 was observed pacing the hallway prior to attacking Patient #2. "Patient #1 was not my assigned patient; my assignment was on the other side of the hallway. I did not hear Patient #1 say anything. I realized there was a problem when I heard Patient #2 yell, 'help me'. At that time all three staff members were in the nursing station and the behavioral health coordinator was on her dinner break. I jumped up, secured the nursing station by locking both the top and bottom of the door on the far side, the medication room door on the top and bottom, and then I started out of the door and the other nurse yelled 'Call a Code Grey'. I grabbed the radio so that I could keep moving toward the situation to help. I really did not know what was going on. I opened the door and saw Patient #1 hitting Patient #2 with his fist. I yelled at him by name and said 'stop'; he looked at me, hit Patient #2 one more time and then he stood up and walked towards me. The next thing I remember is being in the nursing station. We could not get the door shut fast enough. Patient #1 had his fist up like he was going to hit me. Patient #1 told the other nurse and me to get out. The Patient Care Technician unlocked the other door and left out of the other side of the nursing station. The other nurse and I left out of the door we entered through. We then stood at the door to try to make sure Patient #1 did not get out. Patient #2 could still be heard yelling, 'help me help me'.

The House Supervisor responded to the unit and began talking to Patient #1 through the window of the nursing station. He called for a Rapid Response Team. The other nurse and I went into the room and tried to help Patient #2. Patient #2 was given a towel to wrap her head. She was still lying down on her side. Patient #2 was not observed unconscious at any time."

An interview with Employee B on 10/1/2014 at 9:00 am revealed on 9/10/14 that Patient #1 was observed fine and interacting well with the other patients. "I heard from other staff that night that Patient #1 got into it with another patient but I don't know, because I was not there; it was just something I heard. I also heard something about him going into another patient's room, but she always stayed in her room." On the morning of 9/11/14 Patient #1 was observed pacing and standing at the end of the hallway. He was looking out the doors. Employee B stated she asked him if he was OK and he would nod, so, "I did not think anything of it." Employee B stated that she does not usually look at the monitors, because she sees the patients while doing the rounds. "I realized there was a problem when I heard an emergency light alarm and the door shut to the Seclusion Room, and then I heard a scream. We began heading that way; when I got into the room, I saw him straddled over Patient #2 and hitting her. I went to call security and I was told that someone had already called, but I did not go back into the room. I waited for security then I tried to keep the patients in their rooms and tend to them." Employee B stated, "If patients are observed going into another patient's room, then staff will try to stop them and redirect them immediately, then she would let the nurse know". Employee B denied observing Patient #1 going into any other patient rooms; however, "He was observed standing in the hallways at the corners; it made me feel uncomfortable."

An interview with Employee C on 10/1/2014 at 10:37 am revealed that she remembered a patient reporting to her that a doctor kept coming into her room and putting his hand on her arm. That patient was Patient #1 by name and stated that he was in Room 241. That particular patient was assigned to Room 243. Employee C said, "I went into the nursing station and told the charge nurse. I ask him if he had been in to see the patient in Room 243. I informed him that the patient in Room 243 was named Patient #1 by name, and complained that he kept coming into her room, and he said 'OK'.

An interview with BHU Director 10/1/2014 on 9:31am revealed that one of the charge nurse duties is to sit at the desk and watch the monitor. Both nurses are responsible for the daily duties, but just one is considered in charge. The BHU does not have a dedicated staff member assigned to watch the monitor. The charge nurse is expected to observe the monitor while she is documenting; if she has to get up for anything then the other nurse or tech is responsible for watching the monitor. The Unit allowed for additional staff during shift change, to ensure the monitor is watched and that all patients were cared for. The facility did not have a policy directly related to staff monitoring of the surveillance. When shift changes arrive, Patient Care Technicians and Nurse exchange information on behaviors and special interventions. If the patient is on every 2-hour checks, they write it down and pass it to the next shift.

At 10/1/2014 at 10:43 am, the Behavioral Health Director revealed that the Charge Nurse for the day was questioned and he stated that he went to Patient #1 and explained that he was not allowed to go into other patients' rooms. She stated, "The Charge Nurse reported that Patient #1 apologized. It is the expectation of the facility that anything that happens outside of the normal operations should be documented and charted in the medical record. If the staff is made to feel uncomfortable by a patient's presence, or if there is a patient showing unusual behavior, the unit is to immediately report the behaviors to the charge or the attending nurse. The charge nurse should investigate the situation, and determine if further action is warranted. Increased supervision is determined based on the charge nurse's judgment. The facility has a protocol that patients can be offered other medications. If the patients are presenting a danger to themselves or others, then the situation is escalated to include one-to-one or seclusion or restraints if warranted. If patients complain that they cannot sleep due to snoring patients or other disruptive patients and request to go into the Seclusion Room to sleep, they are allowed."

A review of the Patient Rights and Responsibilities Policy and Procedures, with an effective date of 12/16/2013 revealed "A patient has the right to receive care in a safe setting."

A review of the Abuse Assessment Policy and Procedures with an effective date of 1/16/2014 revealed the patient has the right to be free from neglect and exploitation, and verbal, mental, physical, and sexual abuse while in the care of Orange Park Medical Center.
1. Patients will be protected from abuse while the patient is receiving care, treatment, and services.
2. The hospital will evaluate all allegations, observations, and suspected cases of abuse.

A review of the Patient Assessment/Reassessment Policy and Procedures, with an effective date of 1/16/2014 revealed patient reassessments are based on, but are not limited to, changes in condition, patient care needs, or problem identification, and responses to a treatment/ intervention. Patients are reassessed every shift, with a change in condition, change in RN, and as needed.

A0145 - Patient Rights: Free From Abuse
Based on observation of the Behavioral Unit, video observations, patient and staff interviews, and record reviews, the facility failed to protect and prevent abuse to 2 (Patient #2 and Patient #21) of 23 patients that resulted in Immediate jeopardy on 9/11/14 and was ongoing at the time of exit on 10/1/14.

The findings include:

A review of the complaint revealed screams coming from a nearby room will be practically impossible to forget. An unidentified woman was visibly shaken after what she heard early Thursday morning. " I would never forget that sound. It was blood curling; she said. I just keep thinking about her. Since there was so much blood, I can ' t begin to imagine the kind of injuries. I had no idea that could ' ve happened in a hospital. " The Risk Manager stated the Sheriff ' s Office viewed the video and stated that no one can look at the tape and predict what he (Patient #1) would do.

A medical record review for Patient #2 revealed she was admitted into the facility under law enforcement Baker Act on 9/8/2014 with a medical diagnosis. She was stabilized in the Emergency Department. Patient #2 was deemed medically cleared and transported to the Behavioral Health Unit (BHU) on 9/9/2014. A medical record review of Patient #2 ' s current admission revealed she was admitted into the facility on 9/28/2014 with a complaint of seizures. Patient #2 has a history of multiple medical problems. She was treated for a recent head injury secondary to trauma. Patient #2 returned to the facility and was treated for a wound infection and skin graft. The dressing to the skin graft to the posterior head wound is scheduled to be removed on Thursday. A review of the history and physical dated 9/28/2014 revealed Patient #2 is alert and oriented.

An interview with Patient #2 on 9/29/2014 at 7:36pm revealed she was alert and oriented to person, place, time, and situation. Patient #2 named Patient #1. " We (the patients) could tell that he had some aggression issues. " The patients were all in the multipurpose room after playing bingo. There was another patient (Patient #21) who was on a phone call. Patient #1 walked up to him and grabbed the phone and at least two smacks of the phone could be heard in the room due to Patient #21 being hit. Patient #21 walked away and Patient #1 stayed in the multipurpose room. Employee D opened the medication room door and said, " You cannot hit people here. " Patient #2 remembered Patient #1apologizing for it. Patient #1 went out of the multi-purpose room to watch television. Patient #2 stated she fell asleep at about 2:00am. Patient #1 was still in the hallway pacing up and down. The staff had locked the hallway wings on both sides so that patients could be on one side of the wing or the other. Patient #2 stated, " heard the night time crew tell him that, " you cannot be out here; you have to go to your room. " She said nobody reinforced it. Patient #2 stated she eventually got up to go to the bathroom. " I think the only reason he had stopped at my room was because he heard my toilet flush. I walked out of my bathroom and saw Patient #1 standing there. He was not looking into my window. He was looking down the hallway. I went back to sleep and later that morning I heard my door open. Patient #1 was very violent; there were no words in the yelling. He was just yelling. I don ' t remember if he kicked or pushed me down to the floor. He pulled my hands underneath his buttocks sitting on me so I could not fight back. He was yelling and screaming. I remember taking two shots to the face. Then I remember him picking me up by the throat, picking my head up and bashing it into the ground. It was at this point that I blacked out. "

An interview with the Risk Manager on 9/29/14 at 6:32pm revealed that during her investigation of the attack of Patient #2, Patient #1 was observed by the Social Worker in an elderly female patient ' s room, touching her arm. Prior to the attack of Patient #2, Patient #1 was easily re-directed and apologized. On 9/29/14 at 8:30pm the Risk Manager denied knowledge of Patient #1 hitting another patient with a phone while on the BHU. The Risk Manager stated the surveillance video has been reviewed thoroughly by several different agencies and this is the first she has heard about Patient #1 hitting another patient.

An interview with the Security Director on 9/30/14 at 12:10pm, while reviewing the Surveillance video from 9/11/14 revealed that he tracked Patient #1 on the surveillance video from the Emergency Department (ED) to his arrival on the unit starting on 9/10/2014 at 4:01pm, and the BHU from the time Patient #1 arrived into the facility until the incident on 9/11/14 at 3:24am. The Security Director Stated there was no evidence to show that Patient #1 was aggressive or that the attack could have been predicted. The Security Director was asked by the Surveyor about any other incidents involving Patient #1, he stated, " They (other patients) reported that Patient #1 grabbed a phone from another patient to the deputies and their statements were submitted to the Sheriff ' s office " .

An observation of the BHU surveillance video on 9/30/2014 at 12:10pm revealed on 9/10/2014 at 7:59pm Patient #21 is observed on the telephone located on the right side on the video frame; Patient #1 approached that Patient #21 in an aggressive manner. Patient #21 is observed holding the phone and pointing at Patient #1. Patient #1then hit Patient #21 and pushed him into the phone and a weight scale. Patient #1 then pushed the door to the Multi-purpose room closed. Patient #21 who was on phone walked away and a Registered Nurse (RN) (identified by the Security Director) opened the medication room door looking toward Patient #1. Patient #1 walked to the medication door and spoke to the RN. Patient #2 is observed at the table participating in an activity at this time. The video observation was confirmed by the Security Director who was controlling the video speed and rewinding at the request of the Surveyors. Further observation of the BHU surveillance video with a date time stamp of 9/11/14 between the hours of 12:00am - 4:00am revealed Patient #1 walked the hallway on the south side of the care area back and forth. He is observed entering and exiting multiple patient rooms multiple times over several hours. Unit staff is observed passing Patient #1 in the hallways multiple times.
At 2:35am, Patient #1 can be seen entering the seclusion room where Patient #2 is observed sleeping (based on the hallway surveillance video). The seclusion room video revealed an increase in the lighting at the entrance to the seclusion room. Patient #1 cannot be seen entering the seclusion room due to a significant sized blind spot on the video surveillance. The seclusion room light is turned on by Patient #1. Patient #2 is observed from the seclusion room surveillance video sleeping. Patient #2 woke up and walked toward the seclusion room door at 2:36am. The seclusion room door is open and a shadow is present. After Patient #2 approached the door area; only an image of human feet shaking seen at the edge of the camera shot. The hallway surveillance video revealed 2 staff members exiting the nurse ' s station to the seclusion room.
At 2:38am Patient #1 exited the seclusion room and forced himself into the nurse station behind the 2 staff members (who were identified by the Security Director as nurses). The staff nurses are observed exiting the nurse ' s station. A male staff member is observed entering the BHU and standing near the nurse ' s station door and in front of the window blocking visual access to the seclusion room. The 2 nurses can be seen on the surveillance video walking back and forth in the hallway. The simultaneous observation of 2 camera shots revealed Patient #2 was lying on the floor, motionless, on the floor without staff intervention until 2:40 a.m. when the ED staff (identified by the Security Director) arrived to the BHU. At 2:40am, Patient #2 can be seen on the seclusion room video moving around while lying on the floor.

A medical record review for Patient #1 revealed he was walked into the Emergency Department (ED) by his father on 9/8/14 at 6:21pm with a complaint of bizarre behavior for three days. Patient #1 reported that he " hears whispers, but is unable to decipher what they are saying " (auditory hallucinations). A review of the emergency provider note dated 9/9/2014 revealed reports that Patient #1 was at the gym on 9/8/2014 and called someone the devil and stated that he was god. The family of Patient #1 reported that Patient #1 believed he controlled the weather, is having an internal conflict himself and feels he has powers. The family also reported a prior episode of bizarre behavior several months earlier after Patient #1 lost his job. The ED physician ' s assessment revealed Patient #1 was alert and oriented to person, place, and time. The plan for treatment revealed Patient #1 was to be medically clear for a psychiatric evaluation after blood samples for a blood chemistry and urine toxicology were sent and resulted. The ED physician ' s plan is to have Behavioral Health evaluate Patient #1 and assist with the disposition.
A review of the Psychiatric Assessment dated 9/9/2014 at 8:03pm revealed Patient #1 was an involuntary Baker Act patient who had no known history of psychiatric problems. Patient #1 ' s behavior was described as bizarre delusions. Patient #1 denied suicidal and homicidal ideations. Patient #1 ' s thought processes are described as disorganized, bizarre ideations, flight of ideas, illogical, and loose associations. Patient #1 stated that he thought people were evil. He admitted to hearing voices for five days and not sleeping and having racing thoughts.
Patient #1 was admitted onto the Behavioral Health Unit on 9/10/2014 at 2:45pm. The nursing notes dated 9/10/2014 at 8:14pm revealed that Patient #1 was admitted to the unit with standing physician orders. He was cooperative with the admission process and signed for his medications/ treatment. Patient #1 was oriented to the unit, advised to call his family using the access code. Their additional nursing notes that stated, will continue to monitor Patient #1 for safety and encourage coping skills.

At 2:35am on 9/11/14 the nursing notes revealed Patient #1 had been up and about early in the shift. He was medicated with Vistaril, Zyprexa, and Ambien at bedtime. Patient #1 laid down for a few hours and was then observed up and walking the hallway. He was easily re-directed. At approximately 2:23am, yelling was heard from the quiet room. Patient #1 was observed punching Patient #2 in the head repeatedly. The nurse yelled at Patient #1 to stop and placed a hand on his shoulder but, Patient #1 continued hitting Patient #2. Patient #1 had a strange angry look on his face. A code grey was called. The house supervisor, security, and the police responded. Patient #1 followed the nursing staff into the nursing station prior to the response of facility staff to the code grey. He was unreasonable and yelled at the nursing staff to get out. Patient #1 was restrained by the police in the nursing station. The physician was notified and stated the police could take Patient #1 into custody. Patient #1 left the nursing unit with police via wheel chair. The review of the nursing notes does not mention or support the video surveillance of Patient #1 attacking Patient #21 while in the multi-purpose room on 9/10/2014 at 7:59pm; nor do the nursing notes mention or give account of the report of Patient #1 entering an unknown patient room multiple times and touching her. There was no documentation in the medical record to support evidence that Patient #1 was re-assessed for increasing violent behaviors and insomnia.

An interview with Employee A on 10/1/2014 at 8:31am revealed the behavioral staff completes safety rounds every 15 minutes on both day and night shifts. Additionally, there is surveillance video monitor located in the nursing station. Usually the charge nurse will sit at the computer near the monitor and is responsible for observing the monitor throughout the shift. On the early morning of 9/11/14, Patient #1 was observed pacing the hallway prior to attacking Patient #2. Patient #1 was not my assigned patient; my assignment was on the other side of the hallway. " I did not hear Patient #1 say anything. I realized there was a problem when I heard Patient #2 yell help me. At that time all three staff members were in the nursing station and the behavioral health coordinator was on her dinner break. I jumped up, secured the nursing station by locking both the top and bottom of the door on the far side, the medication room door on the top and bottom, and then I started out of the door and the other nurse yelled call a code gray. I grabbed the radio so that I could keep moving toward the situation to help. I really did not know what was going on. I opened the door and saw Patient #1 hitting Patient #2 with his fist. I yell at him by name and said stop, He looked at me, hit Patient #2 one more time and then he stood up and walked towards me. The next thing I remember is being in the nursing station we could not get the door shut fast enough. Patient #1 had his fist up like he was going to hit me. Patient #1 told the other nurse and me to get out. The PCT unlocked the other door and left out of the other side of the nursing station. The other nurse and I left out of the door we entered through. We then stood at the door to try to make sure Patient #1 did not get out. Patient #2 could still be heard yelling help me help me. The House Supervisor responded to the unit and began talking to Patient #1 through the window of the nursing station; he called for a rapid response team. The other nurse and I went into the room and tried to help Patient #2. Patient #2 was given a towel to wrap head she was still lying down on her side. Patient #2 was not observed unconscious at any time " .

An interview with Employee B on 10/1/2014 at 9:00am revealed on 9/10/14, Patient #1 was observed fine and interacting well with the other patients. On the morning of 9/11/14, Patient #1 was observed pacing and standing at the end of the hallway. He was looking out the doors. Employee B stated she asked him if he was OK and he would nod, so " I did not think anything of it " . Employee B stated that she does not usually look at the monitors because she sees the patients while doing the rounds. " I realize there was a problem when I heard an emergency light alarm and the door shut to the seclusion room, and then I heard a scream. We began heading that way; when I got into the room I saw him straddle over her hitting her. I went to call security and I was told that someone had already called but I did not go back into the room. I waited for security then I tried to keep the patients in their rooms and tend to them " . Employee B stated, if patients are observed going into another patient ' s room, then staff will try to stop them and re-direct them immediately; then, she would let the nurse know. Employee B denied observing Patient #1 going into any other patient rooms; however, " he was observed standing in the hallways at the corners, and it made me feel uncomfortable. "

An interview with Employee C on 10/1/2014 at 10:37am revealed that she remembered Patient #22 reporting to her that a doctor kept coming into her room and putting his hand on her arm. Patient #22 named Patent #1 by name and said that he was in Room 241. Patient #22 was assigned to 243. Employee C said, " I went into the nursing station and told the charge nurse. I ask him if he had been in to see Patient #22. I informed him that Patient #22 named Patient #1 by name, and complained that he kept coming into her room and he said OK.

An interview with the BHU Director on 10/1/14 at 9:31am revealed that one of the charge nurse duties is to sit at the desk and watch the monitor. Both nurses are responsible for the daily duties but just one is considered in charge. The BHU does not have a dedicated staff member assigned to watch the monitor. The charge nurse is expected to observe the monitor while she is documenting, if she has to get up for anything then the other nurse or tech is responsible for watching the monitor. The Unit allows for additional staff during shift change to ensure the monitor is watched and that all patients are care for. The facility does not have a policy directly related to staff monitoring of the surveillance. When shift change arrives, Patient Care Technicians and Nurse exchange information on behaviors, special interventions; if the patient is on every 2 hour checks, they write it down and pass it to the next shift.
At 10/1/2014 at 10:43am, the Behavioral Health Director revealed that the charge nurse for the day was questioned and he said that he went to Patient #1 and explained that he was not allowed to go into other patient rooms. She stated the Charge Nurse reported that Patient #1 apologized. It is the expectation of the facility that anything that happens outside of the normal operations should be documented and charted in the medical record.
If the staff is made to feel uncomfortable by a patient ' s presence, or there is a patient showing unusual behavior, the unit is to immediately report the behaviors to the charge or the attending nurse. The charge nurse should investigate the situation, talk to the patient and determine if further action is warranted. Increased supervision is determined based on the charge nurse judgment. The facility has a protocol the patients can be offered other medications. If the patients are presenting a danger to themselves or others then the situation is escalated to include one to one or seclusion or restraints if warranted.
If patients complain that they cannot sleep due to snoring patients or other disruptive patients and request to go into the seclusion room to sleep they are allowed.

A review of the Patient Rights and Responsibilities policy and procedure with an effective date of 12/16/2013 revealed, " A patient has the right to receive care in a safe setting. "
A review of the Abuse Assessment policy and procedure with in effective date of 1/16/2014 revealed the patient has the right to be free from neglect, exploitation; and verbal, mental, physical, and sexual abuse while in the care of Orange Park Medical Center.
1. Patients will be protected from abuse while the patient is receiving care, treatment, and services.
2. The hospital will evaluate all allegations, observations, and suspected cases of abuse.

A review of the Patient Assessment/ Reassessment policy and procedure with an effective date of 1/16/2014 revealed patient re-assessments are based on but not limited to changes in condition, patient care needs, or problem identification, and response to a treatment/ intervention. Patients are re-assessed every shift, with a change in condition, change in RN, and as needed.

A review of the Behavioral Health Abuse Reporting policy and procedure with an effective date of 12/16/2016 revealed:
1. Observations, reports, and assessments of suspected patient abuse are documented in the medical record.

Based on observations, review of facility video footage, staff interviews including the Risk Manager, the Quality Manager, and the Chief Executive Officer, the facility failed to: (1) Develop an immediate plan to ensure patient safety after a patient was attacked on the Behavioral Unit. (2) Failed to ensure that a comprehensive quality assurance program is in place. (Refer to A 0115, A 0142, A 144, A 145 and A 286). The cumulative effect of this incident on the psychiatric unit resulted in the hospital's inability to ensure the provision of quality health care in a safe setting. This resulted in immediate jeopardy on 9/11/14 and it is ongoing at the time of exit on 10/1/14.

The findings include:

Refer to A 286.

Based on observations, review of facility video, patient record review, and staff interviews, the facility failed to provide for the safety of patients admitted to the Behavioral Health Unit.

The findings include:

Review of the medical record for Patient #2 revealed she was admitted to the facility on 9/9/2014 for treatment and care. At 2:36 A.M. on 9/11/2014, Patient #2 was sleeping in the seclusion room on the unit, while Patient #1 roamed the hallway. Patient #1 entered the seclusion room occupied by Patient #2 and assaulted her. Patient #2 was transported to the facility's Emergency Department and admitted with multiple head lacerations requiring 48 staples and stitches to her right ear, a concussion and anemia related to blood loss. Patient #2 was readmitted to the facility on 9/21/2014 for drainage and wound infection and dehiscence of the wound obtained during the assault on 9/11/2014. (The wound edges were separating).

An observation of the Behavioral Health Unit was made on 9/29/2014 at 9:02 P.M. A set of video monitors were positioned at the nurses' station. The seclusion room in which Patient #2 was assaulted was examined on video monitoring while the Chief Nursing Officer, Director of Quality, and the Behavioral Health Director stood in the doorway leading into the seclusion room; only a small portion of a foot could be observed on the monitor representing a deficit in video coverage for this entry.

An interview was conducted with the Risk Manager on 9/29/2014 at 6:32 P.M. and she was asked about what the facility is doing to prevent physical assault from happening in the future on the Behavioral Health Unit and she responded, "Nothing."

An interview was conducted with Patient #2 on 9/29/2014 at 7:36 P.M. and she stated, "There was a man named (Patient #1), we (the patients) can tell that he had some aggression issues. We were all in the multi-purpose room when we had just got done playing Bingo. There was a guy named (She gave the name of Patient #21) who had a phone call. Patient #1 came up to him and grabbed the phone and we heard at least two smacks of the phone being hit on Patient #21."

An interview with the Director of the Behavioral Health Unit was conducted on 10/1/2014 at 9:31 A.M. and she stated, "The charge nurse is responsible for watching the video monitors; they do take a full patient load. They delegate and there has to be someone in charge at night making sure everything goes according to policy and procedures. What I can say is that there is not one person dedicated to solely stare at a monitor. The charge nurse; or any nurse are assigned to watch the monitor while they are documenting; if she has to get up and care for a patient she will ask the nurse in the work station to watch the monitor. There is not a policy for monitoring the video bank at the nurses' station, but I will look."

By exit on 10/1/2014 at 12:30 P.M., no policy and procedure was presented to the survey team related to video monitoring on the Behavioral Health Unit.

An interview was conducted with the Risk Manager on 10/1/2014 at 10:48 A.M. and she stated, "The investigation began at about 5:30 A.M. on 9/11/2014 and the investigation is ongoing to this date. A plan is being formulated at this time. Ordinarily, it would not take this long to investigate. We have had staffing issues that we have had to take care of, and we have had a lot of outside influence. We would do anything to protect the patients. We still have fallout in the emergency department for having not been prepared for that incident-we want to do drills. We have started a behavioral response team that we are looking at getting up and running in a couple of months. You also get a false sense of security when different agencies certified everything and there were no problems identified."

A review of the hospital document entitled Orange Park Medical Center Organizational Clinical Excellence Plan 2014 was conducted. This document revealed the purpose of this plan is to ensure that the Board of Trustees, Medical Staff and hospital staff demonstrate a commitment to creating and sustaining a culture focused on continually improving organizational performance and providing the safest environment possible for patients, employees and visitors.

A review of the date and time stamped video provided by the Director of Security was conducted and found the following events recorded. On 9/10/2014 at 7:59 P.M., Patient #21 was sitting in the Activity Room when he received a phone call given to him by Patient #2. Patient #1 approached Patient #21 who is on the phone in an aggressive manner, moving toward Patient #21 and pointing. Patient #1 hits Patient #21 and pushed him into the phone and weight scale. Patient #1 then pushed the door closed to the Multi-Purpose Room. Patient #2 who was on the phone at the time walked away. Employee D opened the top half of the medication room door looking toward Patient #1 and he walked to the medication room door and spoke with Employee D. A review of documentation for Patient #1 revealed that there is no documentation referencing this behavior.

Based on observation of the Behavioral Unit, video observations, patient and staff interviews, and record review, the facility failed to follow the intermittent plan of care for 1 (Patient #1) of 22 sampled patients.

The findings include:

A medical record revealed Patient #1 was admitted onto the Behavioral Health Unit on 9/10/2014 at 2:45 pm. The nursing notes dated 9/10/2014 at 2:47 pm revealed that Patient #1 was admitted to the unit with standing physician orders. He was cooperative with the admission process, contraband search, and signed for his medications/treatment. There were additional nursing notes that state, "Will continue to monitor for safety awareness and encourage coping skills."

An observation of the BHU surveillance video on 9/30/2014 at 12:10 pm revealed the following on 9/10/2014 at 7:59 pm. Patient #21 is observed on the telephone located on the right side of the video frame. Patient #1 approached Patient #21 in an aggressive manner. Patient #21 is observed holding the phone and pointing at Patient #1. Patient #1then hit Patient #21 and pushed him into the phone and a weight scale. Patient #1 then pushed the door to the Multi-Purpose Room closed. Patient #21 who was on the phone walked away and Employee D (identified by the Security Director) opened the medication room door looking toward Patient #1. Patient #1 walked to the medication room door and spoke to Employee D. Patient #2 is observed at the table participating in an activity at this time. The video observation was confirmed by the Security Director who was controlling the video speed and rewinding at the request of the Surveyors.

Further observation of the BHU surveillance video with a date time stamp of 9/11/14 between the hours of 12:00 am - 4:00 am revealed Patient #1 walked the hallways on the south side of the care area back and forth. He is observed entering and exiting multiple patient rooms multiple times over several hours. Unit staff is observed passing Patient #1 in the hallways multiple times.

At 2:35 am, Patient #1 can be seen entering the seclusion room where Patient #2 is observed sleeping (based on the hallway surveillance video). The seclusion room video revealed an increase in the lighting at the entrance to the seclusion room. Patient #1 cannot be seen entering the seclusion room due to a significant-sized blind spot on the video surveillance. The seclusion room light is turned on by Patient #1. Patient #2 is observed from the seclusion room surveillance video sleeping. Patient #2 woke up and walked toward the seclusion room door at 2:36 am. The seclusion room door is open and a shadow is present. After Patient #2 approached the door area, only an image of human feet shaking were seen at the edge of the camera shot. The hallway surveillance video revealed 2 staff members exiting the nurses' station to the seclusion room.

At 2:38 am Patient #1 exited the seclusion room and forced himself into the nurses' station behind the 2 staff members (who were identified by the Security Director as nurses). The staff nurses are observed exiting the nurses' station. A male staff member is observed entering the BHU and standing near the nurses' station door and in front of the window blocking visual access to the seclusion room. The 2 nurses can be seen on the surveillance video walking back and forth in the hallway. The simultaneous observation of 2 camera shots revealed Patient #2 was lying on the floor, motionless, without staff intervention until 2:40 a.m. when the ED staff (identified by the Security Director) arrived to the BHU. At 2:40 am Patient #2 can be seen in the seclusion room video moving around while lying on the floor.

A medical record review for Patient #1 at 2:35 am on 9/11/14 revealed in the nursing notes that Patient #1 had been up and about early in the shift. Patient #l laid down for a few hours and was then observed up and walking the hallway. At approximately 2:23 am yelling was heard from the Quiet Room. Patient #1 was observed punching Patient #2 in the head repeatedly. The nurse yelled at Patient #1 to stop and placed a hand on his shoulder, but Patient #1 continued hitting Patient #2. Patient #1 had a strange, angry look on his face. A Code Grey was called. The house supervisor, security, and the police responded. Patient #1 followed the nursing staff into the nursing station prior to the response of facility staff to the Code Grey. He was unreasonable and yelled at the nursing staff to get out. Patient #1 was restrained by the police in the nursing station. The physician was notified and stated the police could take Patient #1 into custody. Patient #1 left the nursing unit with police in a wheelchair. The review of the nursing notes does not mention or support the video surveillance of Patient #1 attacking Patient #21 while in the multi-purpose room on 9/10/2014 at 7:59 pm; nor do the nursing notes mention or give account of the report of Patient #1 entering an unknown patient's room multiple times and touching her.

There was no documentation in the medical record to support evidence that Patient #1 was reassessed for increasing violent behaviors and insomnia.

An interview with Employee A on 10/1/2014 at 8:31 am revealed patient behaviors are documented in the medical record under patient goals. If patients are observed with aggressive behaviors then they are documented in patient notes. Patient behaviors are documented once a shift, but if something happens then an additional entry is made as soon as possible after the incident. The behavioral staff completes safety rounds every 15 minutes on both day and night shifts.

Additionally, there is a surveillance video monitor located in the nursing station. Usually, the charge nurse will sit at the computer near the monitor and is responsible for observing the monitor throughout the shift.

"On the early morning of 9/11/14, Patient #1 was observed pacing the hallway prior to attacking Patient #2. Patient #1 was not my assigned patient; my assignment was on the other side of the hallway. I did not hear Patient #1 say anything. I realized there was a problem when I heard Patient #2 yelling, 'help me'. At that time, all three staff members were in the nursing station and the behavioral health coordinator was on her dinner break. I jumped up, secured the nursing station by locking both the top and bottom of the door on the far side, the medication room door on the top and bottom, and then I started out of the door and the other nurse yelled 'Call a Code Grey'. I grabbed the radio so that I could keep moving toward the situation to help. I really did not know what was going on. I opened the door and saw Patient #1 hitting Patient #2 with his fist. I yelled at him by name and said 'stop'. He looked at me, hit Patient #2 one more time and then he stood up and walked toward me. The next thing I remember is being in the nursing station. We could not get the door shut fast enough. Patient #1 had his fist up like he was going to hit me. Patient #1 told the other nurse and me to get out.

The PCT unlocked the other door and left out of the other side of the nursing station. The other nurse and I left out of the door we entered through. We then stood at the door to try to make sure Patient #1 did not get out. Patient #2 could still be heard yelling, 'help me help me'. The House Supervisor responded to the unit and began talking to Patient #1 through the window of the nursing station. He called for a rapid response team. The other nurse and I went into the room and tried to help Patient #2. Patient #2 was given a towel to wrap her head. She was still lying down on her side. Patient #2 was not observed unconscious at any time."

An interview with Employee B on 10/1/2014 at 9:00am revealed on 9/10/14, Patient #1 was observed fine and interacting well with the other patients. " I heard from other staff that night that Patient #1 got into it with another patient but I don ' t know because I was not there, it was just something I heard. I also heard something about him going into another patient ' s room but she always stayed in her room. " On the morning of 9/11/14, Patient #1 was observed pacing and standing at the end of the hallway. He was looking out the doors. Employee B stated she asked him if he was OK and he would nod, so " I did not think anything of it. " Employee B stated that she does not usually look at the monitors because she sees the patients while doing the rounds. " I realize there was a problem when I heard an emergency light alarm and the door shut to the seclusion room, and then I heard a scream. We began heading that way, when I got into the room I saw him straddled over Patient #2 and hitting her. I went to call security and I was told that someone had already called but I did not go back into the room. I waited for security then I tried to keep the patients in their rooms and tend to them. " Employee B stated, if patients are observed going into another patient ' s room, then staff will try to stop them and re-direct them immediately then, she would let the nurse know. Employee B denied observing Patient #1 going into any other patient rooms, however, " he was observed standing in the hallways at the corners; it made me feel uncomfortable. "

An interview with Employee C on 10/1/2014 at 10:37am revealed that she remembers a Patient reporting to her that a doctor kept coming into her room and putting his hand on her arm. That patient was Patient #1 by name and said that he was in Room 241. That particular patient was assigned to 243. Employee C said, " I went into the nursing station and told the charge nurse. I ask him if he had been into see the patient in Room 243. I informed him that the Patient in 243 named Patient #1 by name, and complained that he keeps coming into her room and he said OK.

An interview with BHU Director on 10/1/14 at 9:31am revealed that one of the charge nurse duties is to sit at the desk and watch the monitor. Both nurses are responsible for the daily duties but just one is considered in charge. The BHU does not have a dedicated staff member assigned to watch the monitor. The charge nurse is expected to observe the monitor while she is documenting, if she has to get up for anything then the other nurse or tech is responsible for watching the monitor. The Unit allows for additional staff during shift change to ensure the monitor is watched and that all patients are care for. The facility does not have a policy directly related to staff monitoring of the surveillance. When shift change arrives, Patient Care Technicians and Nurse exchange information on behaviors and special interventions. If the patient is on every 2 hour checks, they write it down and pass it to the next shift.

On 10/1/2014 at 10:43am, the Behavioral Health Director revealed that the charge nurse for the day was questioned and he said that he went to Patient #1 and explained that he was not allowed to go into other patients ' rooms. She said the Charge Nurse reported that Patient #1 apologized. It is the expectation of the facility that anything that happens outside of the normal operations should be documented and charted in the medical record.
If the staff is made to feel uncomfortable by a patient ' s presence, or there is a patient showing unusual behavior the unit is to immediately report the behaviors to the charge or the attending nurse. The charge nurse should investigate the situation, and determine if further action is warranted. Increased supervision is determined based on the charge nurse judgment. The facility has a protocol that patients can be offered other medications. If the patients are presenting a danger to themselves or others then the situation is escalated to include one to one or seclusion or restraints if warranted.