HospitalInspections.org

1) The facility failed to provide patient (P) 1 the right to receive care in a safe setting resulting in P1 getting assaulted by a psychiatric aide (PA) 1 in the Behavioral Health Unit (BHU).

2) The facility failed to provide P1 the right to be free from all forms of abuse or harassment.

Findings Include:

Cross reference to findings at A-0144 and A-0145

Based on facility reported incident (FRI) forwarded to the State Agency, observation, record review (RR), and interviews, the facility failed to provide patient (P) 1 the right to receive care in a safe setting.

Cross Reference: A-0145

Findings Include:

On 11/12/19 at 10:00 AM, review of FRI describing P1 in the Behavioral Health Unit (BHU) exhibiting aggressive behavior by using verbal assaults and threw hot beverage at psychiatric aide (PA) 1. In response to the provocation, PA1 physically assaulted P1 by pulling P1 down from the wheelchair to the ground after punching P1 in the face. P1 sustained abrasions to right forehead, left elbow, left ear, left and right legs. PA1 was immediately placed on administrative leave by house supervisor and subsequently terminated.

On 11/13/19 at 12:50 PM, RR showed PA1 was hired by the facility as a security officer (SO) on 10/29/19. PA1 applied and was hired as a psychiatric aide on 04/02/18 for the BHU. PA1 had completed multiple classes and training including but not limited to Techniques for Effective Aggressive Management (TEAM) Essentials, Identifying and Assessing Victims of Abuse and Neglect, and Patient Rights.

On 11/13/19 at 01:35 PM, RR reflected P1 was admitted to the facility on 06/29/18 with the following diagnoses: Post Traumatic Stress Disorder, Intermittent Explosive Disorder, Depressive Disorder, Cluster B Personality Traits, Incomplete Quadriplegic (06/09/16, traumatic brain injury, motor vehicle versus motorcycle accident), Traumatic Brain Injury, Indwelling Suprapubic Catheter, History of Bacteremia due to Vancomycin-Resistant Enterococcus, Problems with primary support group, social, environmental, occupational, and underlying medical and psychiatric conditions. Records showed P1 was transferred to this facility from another facility due to management problems at the other facility. It was reported P1 was using abusive language towards the treatment team and the situation escalated to the point whereby P1 was not accepted back to that facility. Documentation by consulting psychiatrist dated 07/18/19 noted request by hospitalists to assess P1's mental status and to participate in safe and appropriate disposition. Psychiatrist stated P1 had been causing management problems for staff, providers, other patients, and the general milieu in the acute care units of the facility. There were episodes whereby P1 was yelling, screaming, and using profane language towards staff. P1 also repeatedly threatened facility supervisors. Psychiatrist's advice and recommendation was for P1 to consider voluntary admission/transfer to the BHU. P1 agreed. Psychiatrist documented P1 declined to take antidepressants (Lexapro, and/or Abilify) on advice and recommendation. Psychiatrist stated on 07/15/19, an interdisciplinary team (IDT) meeting revealed P1's insurance informed the facility approval for P1's acute psychiatric status ended that day. It was then discussed and decided by the IDT including facility hospitalists that P1 will be downgraded to intermediate care facility (ICF) while in the BHU.

On 11/14/19 at 02:00 PM, Compliance and Risk Management Officer (CRMO) provided and showed surveyors the video of the incident dated 09/22/19, Sunday at approximately 07:00 AM. This video had two different views of the lanai area but without audio. Observation of said video showed P1 in the BHU being wheeled out in his wheelchair to the open lanai area by PA2. The video showed PA2 left P1 just outside the sliding glass door to the lanai. P1 then rolled himself several feet towards a round table near the sliding glass door. A short moment later, PA2 came out to the lanai and appeared to be conversing with P1. PA2 then left and came back with a cup of beverage and left it on the table for P1. Video then showed PA1 emerging from sliding glass door and in the process of donning rubber gloves. Video appears to show PA1 and P1 speaking to eachother. Not long after, P1 is seen throwing the cup of beverage at PA1. It was then PA1 was seen in the video to lunge at and punch P1 in the face before grabbing P1 by the head/hair and pulling P1 towards the ground. In the video, it appears PA2 was attempting to pull the wheelchair out from underneath P1 (It was confirmed later during interview with PA2 that PA2 was attempting to remove the wheelchair so P1 doesn't get injured or trapped by the wheelchair). After taking P1 to the ground, PA1 then proceeded to place his right knee on P1's head. Moments later, PA1 was seen pulling on P1's hair and dragging P1 several feet and in the process turning P1 from prone to supine position. By then, charge nurse (CN) was seen in the video with the mega mover (canvas gurney) in hand. PA1 was seen squatting next to P1 and they appeared to be conversing. In the video, a SO was seen standing against the wall adjacent to the sliding glass door. It appears the SO was present when PA1 was pinning P1's head with his knee. The video continues to show P1 was placed on the mega mover with PA1 pulling on P1's hair and roughly pushing P1's upper torso down towards the ground. Video clearly showed staff (PA2, SO) were present at the time of the assault and did not attempt to intervene by stopping PA1 or having him removed from the situation or the area.

On 11/15/19 at 12:52 PM, interview with CRMO who stated the video dated 09/22/19 of the incident is very traumatic. CRMO said it was a bad situation of an assault by staff (PA1) on a patient (P1) in the BHU. CRMO said she saw the video the following morning 09/23/19 and requested the BHU staff involved to prepare their statements regarding the incident. CRMO stated she then sat down with each staff to review their statements of the event that took place. CRMO when queried whether she felt the staff involved in the incident responded appropriately to the situation at hand, CRMO stated firmly, "No, I do not." CRMO stated they (facility) are looking into more education and training for staff, not just for staff in the BHU but the facility as a whole.

On 11/15/19 at 07:38 AM, interview with PA2 who stated he did see the video dated 09/22/19 related to the incident. PA2's statement regarding the incident generally mirrored what was seen in the video. PA2 stated PA1 was supposed to be assisting P1 out of bed that morning but because P1 was already irritated at PA1, PA2 was asked by PA1 to get P1 out of bed. PA2 stated P1 was loud and yelling, it was decided to have P1 go out to the lanai so P1 would not disturb other patients who were still asleep. PA2 said as he was pushing P1 out to the lanai, P1 and PA1 were exchanging words with P1 threatening PA1 saying "If I had a gun, I would shoot you." PA2 stated P1 and PA1 were swearing and flipping eachother off with hand gestures. PA2 stated he had noticed P1 who was now out in the lanai was still having interaction with PA1 through the sliding glass door. PA2 said he was going back and forth from the lanai to the nurse's station because he had to give P1 the requested beverage and also inform P1's nurse about what was happening. PA2 stated P1's nurse told him he was already in the process of getting P1's medications ready. PA2 said when he got back out to the lanai, he heard PA1 saying something like "Don't throw that tea at me" to P1. PA2 said he then heard PA1 say "You better not throw that at me." But when P1 threw the tea at PA1, that's when PA1 reacted in a "Violent way." PA2 said PA1 hit or like punched P1 in the face and was pulling P1 off the wheelchair and down to the ground. PA2 said he was in shock and all he could think of was to attempt to remove the wheelchair so P1 doesn't get injured since he was unable to secure P1 back into the wheelchair. PA2 admitted he froze in shock and did not attempt to intervene. PA2 confirms SO was present at the time. PA2 stated he feels adequate and effective working in the BHU even though with not much training but could use some training and learn another technique on how to de-escalate similar situation in the future.

On 11/15/19 at 09:38 AM, interview with charge nurse (CN) who stated he has been working in BHU night shift for 20 years. CN stated he is aware of the incident on 09/22/19 at around 07:00 AM which turned out to be an assault on P1 by PA1. CN stated he did not see the video of the incident because "I have no interest in seeing violence." CN stated he only knew the details about the incident/assault from co-workers talking about it. CN denied knowing or seeing PA1 assaulting P1. CN confirmed he heard P1 yelling at PA1 but felt PA2 would be able to take care of the situation because PA2 was already taking P1 out to the lanai. CN stated he was busy at the nurse's station and still hear P1 yelling outside. CN said the next thing he saw was PA2 coming from outside and waving at him. CN stated he looked out and saw P1 on the floor. CN said he quickly grabbed the mega mover and went outside. CN stated he asked what happened and no one said anything except PA1. CN said PA1 told him P1 threw tea at him and did not stop yelling and we need to put P1 in open seclusion room. CN said PA1 stated P1 was fighting with good hand and needed to be taken down to the floor. CN stated he saw P1 had a bleeding mouth, a lump on the forehead, and scrapes on palms and forearms. When queried what he did next, CN stated he got the mega mover and preparing to put P1 on it. CN said he isn't exactly sure who assisted in moving P1 onto the mega mover but by then, day shift staff arrived and assisted. CN stated he was already passed his time to leave which was 07:15 AM and did not have a ride home. CN stated he quickly documented the incident in progress notes and caught a ride home with PA1. CN denied discussing the incident with PA1 while riding home with him. CN admitted he knew from several days back that P1 did not want PA1 to help him. CN said because of that, he would help P1 whenever he was the charge nurse. Queried CN what he did to ensure PA1 will not have contact with P1. CN stated "Honestly, nothing." CN said patients that are not assigned, they all share the work at night. CN admitted after reading the progress notes he wrote regarding the incident on 09/22/19, it was only partially accurate. CN admitted he was told by staff (PA1 & PA2) as to what happened that day. CN concurred he should have wrote in the progress notes he was told by staff as to what happened that day instead of writing as if he witnessed it himself.

On 11/19/19 at 01:00 PM, interview with psychiatrist who confirms he saw the the video dated 09/22/19 of the assault on P1 by PA1. Psychiatrist stated because of this incident, the facility is now in "Damage Control." Psychiatrist stated P1 is a difficult patient to manage and other facilities were not able to care for P1 prior to his admission to this facility. Psychiatrist stated P1 has been threatening and abusive to staff, and at times even threw things at them without provocation. Psychiatrist said P1 agreed to stay in BHU voluntarily/own free will. Psychiatrist stated he did a psychiatric capacity assessment on P1 on 02/05/19 and the result basically showed P1 is capable of making his own decisions. Psychiatrist stated because P1 is an intermediate care facility (ICF) patient who agreed to voluntarily be in the BHU, he (psychiatrist) will only see P1 as needed or per request. When queried by surveyors regarding P1's psychological effects from this incident, psychiatrist stated "Certainly, to some degree traumatized by the assault." Psychiatrist stated P1 has had less outbursts and is more aware and self reflects on his behaviors toward others. Psychiatrist said P1 does not want to "sabotage" the right to remain in the BHU of this facility. Psychiatrist agreed that if staff had more training, it may have been possible to have prevented this incident.

On 11/15/19 at 07:42 AM and 11/19/19 at 10:08 AM, interview with Director of Clinical Services for BHU (DCS-BHU). DCS-BHU stated she was not present on day of incident which was a Sunday. DCS-BHU stated she got an e-mail regarding the incident from house supervisor and saw the video the following day, Monday. DCS-BHU stated they (management) had a debriefing with the BHU staff Monday morning regarding the incident. DCS-BHU stated some of the night shift staff that were involved in the incident may not have been present. DCS-BHU said they discussed options that staff can implement for a difficult patient. DCS-BHU stated they talked about how staff could handle a situation like this better next time it happens. DCS-BHU said they spoke about what each staff should do in a situation like this but did not discuss what a staff should do if they were witnessing a situation like this. DCS-BHU stated the interdisciplinary team (IDT) has determined BHU is the preferred unit for P1 at this time. DCS-BHU stated P1 is in the BHU voluntarily, he is able to sign himself out any time but P1 chooses to remain in the BHU. DCS-BHU when queried by surveyor stated the SO in the BHU is able to put hands-on during a crisis situation, though it did not happen with this incident on 09/22/19. DCS-BHU stated the facility has elected to move away from Crisis prevention Institution (CPI) training and now uses the concept of Techniques for Effective Aggression Management (TEAM) instead. DCS-BHU stated there are two components to the TEAM concept, one is the TEAM Essentials and the other is TEAM Advanced. DCS-BHU said the TEAM training is on-line through Healthstream.com. DCS-BHU stated the BHU staff are required to take the TEAM Essentials training but not the TEAM Advanced training which is the hands-on portion of the TEAM concept. DCS-BHU stated she is not sure why BHU staff are not required to take the TEAM Advanced training but moving forward, the facility will require BHU staff to take TEAM Advanced training. DCS-BHU stated the facility is now putting the TEAM Advanced training requirement for BHU staff in their policy ("Code Gray" Combative Person).

On 11/19/19 at 11:48 AM, RR of policy for "Code Gray" Combative Person (Policy Stat ID: 5333602 and 4066435) reflected a revision (5333602) dated 08/2019 and pending review. The revised "Code Gray" Combative Person policy (Stat ID: 5333602) under section XI. Training: B. "Emergency Department, Behavioral Health, Intensive Care Unit and Hawaii Island Family Health Clinic employees will also be required to complete TEAM Advanced training. The previous "Code Gray" Combative Person policy (Stat ID: 4066435) with effective date of 10/2015 under section XI. "Training," reflected no TEAM Advanced training requirement for BHU staff, only that the facility will have available training sessions for the following: 1) Awareness of nonverbal communication during interventions, 2) Identifying key components involved in paraverbal communication, 3) Identifying different levels of defensive behaviors, 4) Understanding factors which precipitate escalating behavior.

On 11/19/19 at 12:10 PM, RR of policy for "Handling Irate Customers" (Policy Stat ID: 5485825) under section III. Policy: A. "When dealing with an irate patient or visitor, attempt non-physical intervention prior to physical intervention (defending oneself or protecting another person in imminent harm)." Under section IV. Procedure: A. (4)(b) "Call for the department manager, charge nurse, or house supervisor to take control of the situation." (d) "If the situation worsens, activate the "Code Gray" by dialing *06 and begin announcing three times over the phone "Code Gray" and state department and/or room number if known."

11/20/19 at 10:15 AM, interview P1 with assistance from social worker (SW). Conversation with P1 regarding incident on 09/22/19 reflected P1 had episodes of clarity. P1 stated on day of incident, PA1 was giving him the "finger" underneath his jacket. P1 said he had tea with him but was not hot. P1 stated PA1 was marching towards the door (sliding glass door leading to the lanai) in a "rage-like look." P1 said "He zeroed in on me and coming to get me." P1 stated he tried to put tea on table, everyone made a bigger deal of the drink versus me. During the interview P1 was rambling and difficult to interrupt for any questions. P1 stated he remembers being dragged to the ground by his hair and knee to the head by PA1. P1 stated he was scared and worried about his neck getting more injured than it already is. P1 would talk about this incident but starts talking about another incident and possibly referring to yet another incident. It was difficult at times to decipher which incident P1 was talking about. But one thing was clear, P1 specifically remembers PA1 dragging him down to the ground, PA1 then placed his knee on his head, and dragged him by his hair. P1 stated the whole time, he was scared for his neck because he already has neck injuries. P1 questioned the status of the police investigation and was redirected to the SW for his questions. P1 denies the facility formally interviewed him regarding this assault incident on 09/22/19.

On 11/20/19 at 09:06 AM, interview with SO who was present on day of incident. SO stated he has been working not as a regular but as a part time security officer for this facility for the past 10 years. SO said this was not his regular site, hospice was. SO said on day of incident, he was standing outside P1's room because P1 was loud, belligerent, and using abusive language while staff were caring for him. SO stated P1 was then transported in his wheelchair by PA2 to the lanai. SO stated enroute to the lanai, P1 and PA1 were exchanging foul and abusive language with eachother. SO said at one point, he distinctly heard PA1 telling P1 "Oh yeah! You remember what happened the other day, eh?" SO stated he did not inform staff or anyone else about the comments PA1 made or the heated exchange the two (P1 & PA1) were having. SO stated he was sitting in the day area when PA2 came and requested he open the quiet room because they were going to put P1 in the open seclusion room because P1 was getting too loud and disturbing other patients. SO was queried who makes the decision as to when a patient goes into the open seclusion room. SO stated he doesn't know but thinks the PAs are allowed to. SO said after unlocking and checking the quiet room which is used for open seclusion, he came out and saw PA1 heading for the lanai. SO said a moment later, he saw liquid flying through the air, PA1 grabbing P1's head and pulling P1 off the wheelchair and to the ground. SO said he headed towards the sliding glass door leading to the lanai and found PA1 had P1 pinned to the ground. SO said he did attempt to intervene by telling PA1 to "Stop! Stop!" but with all the commotion and exchange of profanity between PA1 and P1; PA1 did not hear him. SO stated he was in shock and did not think of intervening again or to separate PA1 and P1. SO stated he did not call for a "Code Gray" because his radio was inside the nurse's station and that's the way its always been. SO agreed that maybe he could and should have done more in that situation but was not instructed by the facility as to how to handle that kind of situation. SO stated "I can see we need more hands-on training."

On 11/20/19 at 12:12 PM, interview with Chief Nursing Officer (CNO) who confirms they had a debriefing with the BHU staff the next morning (09/23/19, Monday) regarding the incident on 09/22/19. CNO stated that Monday after the incident, administrative staff huddled to discuss interventions and plans for a situation like this going forward. It was also decided at that time, the CRMO will be the person to work with P1 regarding this incident and to give feedback. CNO stated in his view there may have been some "Disconnect with the IDT." CNO stated everyone may not have been on the same page in relation to implementation of education and training for staff. Which is why when surveyors queried department heads whether security officers are allowed to put hands-on in a crisis situation, some department heads will say yes and some say no. CNO stated he is fully aware of the documentation by the CN in the electronic medical record (which is a legal record) for P1 regarding the incident on 09/22/19 is not completely accurate. CNO stated he has viewed the video of the incident and it does not match what the CN wrote in his notes. CNO said moving forward, they will have more training and in-servicing for facility staff to provide good and accurate documentation.

Based on facility reported incident (FRI) forwarded to the State Agency, observation, record review (RR), and interviews, the facility failed to provide patient (P) 1 the right to be free from all forms of abuse and harassment.

Cross Reference: A-0144

Findings Include:

On 11/12/19 at 10:00 AM, review of FRI describing P1 in the Behavioral Health Unit (BHU) exhibiting aggressive behavior by using verbal assaults and threw hot beverage at psychiatric aide (PA) 1. In response to the provocation, PA1 physically assaulted P1 by pulling P1 down from the wheelchair to the ground after punching P1 in the face. P1 sustained abrasions to right forehead, left elbow, left ear, left and right legs. PA1 was immediately placed on administrative leave by house supervisor and subsequently terminated.

On 11/13/19 at 12:50 PM, RR showed PA1 was hired by the facility as a security officer (SO) on 10/29/19. PA1 applied and was hired as a psychiatric aide on 04/02/18 for the BHU. PA1 had completed multiple classes and training including but not limited to Techniques for Effective Aggressive Management (TEAM) Essentials, Identifying and Assessing Victims of Abuse and Neglect, and Patient Rights.

On 11/13/19 at 01:35 PM, RR reflected P1 was admitted to the facility on 06/29/18 with the following diagnoses: Post Traumatic Stress Disorder, Intermittent Explosive Disorder, Depressive Disorder, Cluster B Personality Traits, Incomplete Quadriplegic (06/09/16, traumatic brain injury, motor vehicle versus motorcycle accident), Traumatic Brain Injury, Indwelling Suprapubic Catheter, History of Bacteremia due to Vancomycin-Resistant Enterococcus, Problems with primary support group, social, environmental, occupational, and underlying medical and psychiatric conditions. Records showed P1 was transferred to this facility from another facility due to management problems at the other facility. It was reported P1 was using abusive language towards the treatment team and the situation escalated to the point whereby P1 was not accepted back to that facility. Documentation by consulting psychiatrist dated 07/18/19 noted request by hospitalists to assess P1's mental status and to participate in safe and appropriate disposition. Psychiatrist stated P1 had been causing management problems for staff, providers, other patients, and the general milieu in the acute care units of the facility. There were episodes whereby P1 was yelling, screaming, and using profane language towards staff. P1 also repeatedly threatened facility supervisors. Psychiatrist's advice and recommendation was for P1 to consider voluntary admission/transfer to the BHU. P1 agreed. Psychiatrist documented P1 declined to take antidepressants (Lexapro, and/or Abilify) on advice and recommendation. Psychiatrist stated on 07/15/19, an interdisciplinary team (IDT) meeting revealed P1's insurance informed the facility approval for P1's acute psychiatric status ended that day. It was then discussed and decided by the IDT including facility hospitalists that P1 will be downgraded to intermediate care facility (ICF) while in the BHU.

On 11/14/19 at 02:00 PM, Compliance and Risk Management Officer (CRMO) provided and showed surveyors the video of the incident dated 09/22/19, Sunday at approximately 07:00 AM. This video had two different views of the lanai area but without audio. Observation of said video showed P1 in the BHU being wheeled out in his wheelchair to the open lanai area by PA2. The video showed PA2 left P1 just outside the sliding glass door to the lanai. P1 then rolled himself several feet towards a round table near the sliding glass door. A short moment later, PA2 came out to the lanai and appeared to be conversing with P1. PA2 then left and came back with a cup of beverage and left it on the table for P1. Video then showed PA1 emerging from sliding glass door and in the process of donning rubber gloves. Video appears to show PA1 and P1 speaking to eachother. Not long after, P1 is seen throwing the cup of beverage at PA1. It was then PA1 was seen in the video to lunge at and punch P1 in the face before grabbing P1 by the head/hair and pulling P1 towards the ground. In the video, it appears PA2 was attempting to pull the wheelchair out from underneath P1 (It was confirmed later during interview with PA2 that PA2 was attempting to remove the wheelchair so P1 doesn't get injured or trapped by the wheelchair). After taking P1 to the ground, PA1 then proceeded to place his right knee on P1's head. Moments later, PA1 was seen pulling on P1's hair and dragging P1 several feet and in the process turning P1 from prone to supine position. By then, charge nurse (CN) was seen in the video with the mega mover (canvas gurney) in hand. PA1 was seen squatting next to P1 and they appeared to be conversing. In the video, a SO was seen standing against the wall adjacent to the sliding glass door. It appears the SO was present when PA1 was pinning P1's head with his knee. The video continues to show P1 was placed on the mega mover with PA1 pulling on P1's hair and roughly pushing P1's upper torso down towards the ground. Video clearly showed staff (PA2, SO) were present at the time of the assault and did not attempt to intervene by stopping PA1 or having him removed from the situation or the area.

On 11/15/19 at 12:52 PM, interview with CRMO who stated the video dated 09/22/19 of the incident is very traumatic. CRMO said it was a bad situation of an assault by staff (PA1) on a patient (P1) in the BHU. CRMO said she saw the video the following morning 09/23/19 and requested the BHU staff involved to prepare their statements regarding the incident. CRMO stated she then sat down with each staff to review their statements of the event that took place. CRMO when queried whether she felt the staff involved in the incident responded appropriately to the situation at hand, CRMO stated firmly, "No, I do not." CRMO stated they (facility) are looking into more education and training for staff, not just for staff in the BHU but the facility as a whole.

On 11/15/19 at 07:38 AM, interview with PA2 who stated he did see the video dated 09/22/19 related to the incident. PA2's statement regarding the incident generally mirrored what was seen in the video. PA2 stated PA1 was supposed to be assisting P1 out of bed that morning but because P1 was already irritated at PA1, PA2 was asked by PA1 to get P1 out of bed. PA2 stated P1 was loud and yelling, it was decided to have P1 go out to the lanai so P1 would not disturb other patients who were still asleep. PA2 said as he was pushing P1 out to the lanai, P1 and PA1 were exchanging words with P1 threatening PA1 saying "If I had a gun, I would shoot you." PA2 stated P1 and PA1 were swearing and flipping eachother off with hand gestures. PA2 stated he had noticed P1 who was now out in the lanai was still having interaction with PA1 through the sliding glass door. PA2 said he was going back and forth from the lanai to the nurse's station because he had to give P1 the requested beverage and also inform P1's nurse about what was happening. PA2 stated P1's nurse told him he was already in the process of getting P1's medications ready. PA2 said when he got back out to the lanai, he heard PA1 saying something like "Don't throw that tea at me" to P1. PA2 said he then heard PA1 say "You better not throw that at me." But when P1 threw the tea at PA1, that's when PA1 reacted in a "Violent way." PA2 said PA1 hit or like punched P1 in the face and was pulling P1 off the wheelchair and down to the ground. PA2 said he was in shock and all he could think of was to attempt to remove the wheelchair so P1 doesn't get injured since he was unable to secure P1 back into the wheelchair. PA2 admitted he froze in shock and did not attempt to intervene. PA2 confirms SO was present at the time. PA2 stated he feels adequate and effective working in the BHU even though with not much training but could use some training and learn another technique on how to de-escalate similar situation in the future.

On 11/15/19 at 09:38 AM, interview with charge nurse (CN) who stated he has been working in BHU night shift for 20 years. CN stated he is aware of the incident on 09/22/19 at around 07:00 AM which turned out to be an assault on P1 by PA1. CN stated he did not see the video of the incident because "I have no interest in seeing violence." CN stated he only knew the details about the incident/assault from co-workers talking about it. CN denied knowing or seeing PA1 assaulting P1. CN confirmed he heard P1 yelling at PA1 but felt PA2 would be able to take care of the situation because PA2 was already taking P1 out to the lanai. CN stated he was busy at the nurse's station and still hear P1 yelling outside. CN said the next thing he saw was PA2 coming from outside and waving at him. CN stated he looked out and saw P1 on the floor. CN said he quickly grabbed the mega mover and went outside. CN stated he asked what happened and no one said anything except PA1. CN said PA1 told him P1 threw tea at him and did not stop yelling and we need to put P1 in open seclusion room. CN said PA1 stated P1 was fighting with good hand and needed to be taken down to the floor. CN stated he saw P1 had a bleeding mouth, a lump on the forehead, and scrapes on palms and forearms. When queried what he did next, CN stated he got the mega mover and preparing to put P1 on it. CN said he isn't exactly sure who assisted in moving P1 onto the mega mover but by then, day shift staff arrived and assisted. CN stated he was already passed his time to leave which was 07:15 AM and did not have a ride home. CN stated he quickly documented the incident in progress notes and caught a ride home with PA1. CN denied discussing the incident with PA1 while riding home with him. CN admitted he knew from several days back that P1 did not want PA1 to help him. CN said because of that, he would help P1 whenever he was the charge nurse. Queried CN what he did to ensure PA1 will not have contact with P1. CN stated "Honestly, nothing." CN said patients that are not assigned, they all share the work at night. CN admitted after reading the progress notes he wrote regarding the incident on 09/22/19, it was only partially accurate. CN admitted he was told by staff (PA1 & PA2) as to what happened that day. CN concurred he should have wrote in the progress notes he was told by staff as to what happened that day instead of writing as if he witnessed it himself.

On 11/19/19 at 01:00 PM, interview with psychiatrist who confirms he saw the the video dated 09/22/19 of the assault on P1 by PA1. Psychiatrist stated because of this incident, the facility is now in "Damage Control." Psychiatrist stated P1 is a difficult patient to manage and other facilities were not able to care for P1 prior to his admission to this facility. Psychiatrist stated P1 has been threatening and abusive to staff, and at times even threw things at them without provocation. Psychiatrist said P1 agreed to stay in BHU voluntarily/own free will. Psychiatrist stated he did a psychiatric capacity assessment on P1 on 02/05/19 and the result basically showed P1 is capable of making his own decisions. Psychiatrist stated because P1 is an intermediate care facility (ICF) patient who agreed to voluntarily be in the BHU, he (psychiatrist) will only see P1 as needed or per request. When queried by surveyors regarding P1's psychological effects from this incident, psychiatrist stated "Certainly, to some degree traumatized by the assault." Psychiatrist stated P1 has had less outbursts and is more aware and self reflects on his behaviors toward others. Psychiatrist said P1 does not want to "sabotage" the right to remain in the BHU of this facility. Psychiatrist agreed that if staff had more training, it may have been possible to have prevented this incident.

On 11/15/19 at 07:42 AM and 11/19/19 at 10:08 AM, interview with Director of Clinical Services for BHU (DCS-BHU). DCS-BHU stated she was not present on day of incident which was a Sunday. DCS-BHU stated she got an e-mail regarding the incident from house supervisor and saw the video the following day, Monday. DCS-BHU stated they (management) had a debriefing with the BHU staff Monday morning regarding the incident. DCS-BHU stated some of the night shift staff that were involved in the incident may not have been present. DCS-BHU said they discussed options that staff can implement for a difficult patient. DCS-BHU stated they talked about how staff could handle a situation like this better next time it happens. DCS-BHU said they spoke about what each staff should do in a situation like this but did not discuss what a staff should do if they were witnessing a situation like this. DCS-BHU stated the interdisciplinary team (IDT) has determined BHU is the preferred unit for P1 at this time. DCS-BHU stated P1 is in the BHU voluntarily, he is able to sign himself out any time but P1 chooses to remain in the BHU. DCS-BHU when queried by surveyor stated the SO in the BHU is able to put hands-on during a crisis situation, though it did not happen with this incident on 09/22/19. DCS-BHU stated the facility has elected to move away from Crisis prevention Institution (CPI) training and now uses the concept of Techniques for Effective Aggression Management (TEAM) instead. DCS-BHU stated there are two components to the TEAM concept, one is the TEAM Essentials and the other is TEAM Advanced. DCS-BHU said the TEAM training is on-line through Healthstream.com. DCS-BHU stated the BHU staff are required to take the TEAM Essentials training but not the TEAM Advanced training which is the hands-on portion of the TEAM concept. DCS-BHU stated she is not sure why BHU staff are not required to take the TEAM Advanced training but moving forward, the facility will require BHU staff to take TEAM Advanced training. DCS-BHU stated the facility is now putting the TEAM Advanced training requirement for BHU staff in their policy ("Code Gray" Combative Person).

On 11/19/19 at 11:48 AM, RR of policy for "Code Gray" Combative Person (Policy Stat ID: 5333602 and 4066435) reflected a revision (5333602) dated 08/2019 and pending review. The revised "Code Gray" Combative Person policy (Stat ID: 5333602) under section XI. Training: B. "Emergency Department, Behavioral Health, Intensive Care Unit and Hawaii Island Family Health Clinic employees will also be required to complete TEAM Advanced training. The previous "Code Gray" Combative Person policy (Stat ID: 4066435) with effective date of 10/2015 under section XI. "Training," reflected no TEAM Advanced training requirement for BHU staff, only that the facility will have available training sessions for the following: 1) Awareness of nonverbal communication during interventions, 2) Identifying key components involved in paraverbal communication, 3) Identifying different levels of defensive behaviors, 4) Understanding factors which precipitate escalating behavior.

On 11/19/19 at 12:10 PM, RR of policy for "Handling Irate Customers" (Policy Stat ID: 5485825) under section III. Policy: A. "When dealing with an irate patient or visitor, attempt non-physical intervention prior to physical intervention (defending oneself or protecting another person in imminent harm)." Under section IV. Procedure: A. (4)(b) "Call for the department manager, charge nurse, or house supervisor to take control of the situation." (d) "If the situation worsens, activate the "Code Gray" by dialing *06 and begin announcing three times over the phone "Code Gray" and state department and/or room number if known."

11/20/19 at 10:15 AM, interview P1 with assistance from social worker (SW). Conversation with P1 regarding incident on 09/22/19 reflected P1 had episodes of clarity. P1 stated on day of incident, PA1 was giving him the "finger" underneath his jacket. P1 said he had tea with him but was not hot. P1 stated PA1 was marching towards the door (sliding glass door leading to the lanai) in a "rage-like look." P1 said "He zeroed in on me and coming to get me." P1 stated he tried to put tea on table, everyone made a bigger deal of the drink versus me. During the interview P1 was rambling and difficult to interrupt for any questions. P1 stated he remembers being dragged to the ground by his hair and knee to the head by PA1. P1 stated he was scared and worried about his neck getting more injured than it already is. P1 would talk about this incident but starts talking about another incident and possibly referring to yet another incident. It was difficult at times to decipher which incident P1 was talking about. But one thing was clear, P1 specifically remembers PA1 dragging him down to the ground, PA1 then placed his knee on his head, and dragged him by his hair. P1 stated the whole time, he was scared for his neck because he already has neck injuries. P1 questioned the status of the police investigation and was redirected to the SW for his questions. P1 denies the facility formally interviewed him regarding this assault incident on 09/22/19.

On 11/20/19 at 09:06 AM, interview with SO who was present on day of incident. SO stated he has been working not as a regular but as a part time security officer for this facility for the past 10 years. SO said this was not his regular site, hospice was. SO said on day of incident, he was standing outside P1's room because P1 was loud, belligerent, and using abusive language while staff were caring for him. SO stated P1 was then transported in his wheelchair by PA2 to the lanai. SO stated enroute to the lanai, P1 and PA1 were exchanging foul and abusive language with eachother. SO said at one point, he distinctly heard PA1 telling P1 "Oh yeah! You remember what happened the other day, eh?" SO stated he did not inform staff or anyone else about the comments PA1 made or the heated exchange the two (P1 & PA1) were having. SO stated he was sitting in the day area when PA2 came and requested he open the quiet room because they were going to put P1 in the open seclusion room because P1 was getting too loud and disturbing other patients. SO was queried who makes the decision as to when a patient goes into the open seclusion room. SO stated he doesn't know but thinks the PAs are allowed to. SO said after unlocking and checking the quiet room which is used for open seclusion, he came out and saw PA1 heading for the lanai. SO said a moment later, he saw liquid flying through the air, PA1 grabbing P1's head and pulling P1 off the wheelchair and to the ground. SO said he headed towards the sliding glass door leading to the lanai and found PA1 had P1 pinned to the ground. SO said he did attempt to intervene by telling PA1 to "Stop! Stop!" but with all the commotion and exchange of profanity between PA1 and P1; PA1 did not hear him. SO stated he was in shock and did not think of intervening again or to separate PA1 and P1. SO stated he did not call for a "Code Gray" because his radio was inside the nurse's station and that's the way its always been. SO agreed that maybe he could and should have done more in that situation but was not instructed by the facility as to how to handle that kind of situation. SO stated "I can see we need more hands-on training."

On 11/20/19 at 12:12 PM, interview with Chief Nursing Officer (CNO) who confirms they had a debriefing with the BHU staff the next morning (09/23/19, Monday) regarding the incident on 09/22/19. CNO stated that Monday after the incident, administrative staff huddled to discuss interventions and plans for a situation like this going forward. It was also decided at that time, the CRMO will be the person to work with P1 regarding this incident and to give feedback. CNO stated in his view there may have been some "Disconnect with the IDT." CNO stated everyone may not have been on the same page in relation to implementation of education and training for staff. Which is why when surveyors queried department heads whether security officers are allowed to put hands-on in a crisis situation, some department heads will say yes and some say no. CNO stated he is fully aware of the documentation by the CN in the electronic medical record (which is a legal record) for P1 regarding the incident on 09/22/19 is not completely accurate. CNO stated he has viewed the video of the incident and it does not match what the CN wrote in his notes. CNO said moving forward, they will have more training and in-servicing for facility staff to provide good and accurate documentation.

A registered nurse (RN) must evaluate the care for each patient upon admission and when appropriate on an ongoing basis in accordance with the accepted standards of nursing practice and hospital policy. Evaluation would include assessing the patient's care needs, patient's health status/conditioning, as well as the patient's response to interventions.

The facility's RNs in the BHU failed to appropriately evaluate P1's care needs and assess P1's response to interventions on an ongoing basis resulting in P1 getting assaulted by PA1 even though the RNs had knowledge that PA1 was a trigger for P1, in addition to P1 requesting not to receive care from PA1.

Findings Include:

Cross reference to findings at A-0395

Observations, record review (RR), and interviews, the facility's RNs in the BHU failed to appropriately evaluate P1's care needs and assess P1's response to interventions on an ongoing basis resulting in P1 getting assaulted by PA1 even though the RNs had knowledge that PA1 was a trigger for P1, in addition to P1 requesting not to receive care from PA1.

Findings Include:

On 11/12/19 at 10:00 AM, review of FRI describing P1 in the Behavioral Health Unit (BHU) exhibiting aggressive behavior by using verbal assaults and threw hot beverage at psychiatric aide (PA) 1. In response to the provocation, PA1 physically assaulted P1 by pulling P1 down from the wheelchair to the ground after punching P1 in the face. P1 sustained abrasions to right forehead, left elbow, left ear, left and right legs. PA1 was immediately placed on administrative leave by house supervisor and subsequently terminated.

On 11/13/19 at 12:50 PM, RR showed PA1 was hired by the facility as a security officer (SO) on 10/29/19. PA1 applied and was hired as a psychiatric aide on 04/02/18 for the BHU. PA1 had completed multiple classes and training including but not limited to Techniques for Effective Aggressive Management (TEAM) Essentials, Identifying and Assessing Victims of Abuse and Neglect, and Patient Rights.

On 11/13/19 at 01:35 PM, RR reflected P1 was admitted to the facility on 06/29/18 with the following diagnoses: Post Traumatic Stress Disorder, Intermittent Explosive Disorder, Depressive Disorder, Cluster B Personality Traits, Incomplete Quadriplegic (06/09/16, traumatic brain injury, motor vehicle versus motorcycle accident), Traumatic Brain Injury, Indwelling Suprapubic Catheter, History of Bacteremia due to Vancomycin-Resistant Enterococcus, Problems with primary support group, social, environmental, occupational, and underlying medical and psychiatric conditions. Records showed P1 was transferred to this facility from another facility due to management problems at the other facility. It was reported P1 was using abusive language towards the treatment team and the situation escalated to the point whereby P1 was not accepted back to that facility. Documentation by consulting psychiatrist dated 07/18/19 noted request by hospitalists to assess P1's mental status and to participate in safe and appropriate disposition. Psychiatrist stated P1 had been causing management problems for staff, providers, other patients, and the general milieu in the acute care units of the facility. There were episodes whereby P1 was yelling, screaming, and using profane language towards staff. P1 also repeatedly threatened facility supervisors. Psychiatrist's advice and recommendation was for P1 to consider voluntary admission/transfer to the BHU. P1 agreed. Psychiatrist documented P1 declined to take antidepressants (Lexapro, and/or Abilify) on advice and recommendation. Psychiatrist stated on 07/15/19, an interdisciplinary team (IDT) meeting revealed P1's insurance informed the facility approval for P1's acute psychiatric status ended that day. It was then discussed and decided by the IDT including facility hospitalists that P1 will be downgraded to intermediate care facility (ICF) while in the BHU.

On 11/14/19 at 02:00 PM, Compliance and Risk Management Officer (CRMO) provided and showed surveyors the video of the incident dated 09/22/19, Sunday at approximately 07:00 AM. This video had two different views of the lanai area but without audio. Observation of said video showed P1 in the BHU being wheeled out in his wheelchair to the open lanai area by PA2. The video showed PA2 left P1 just outside the sliding glass door to the lanai. P1 then rolled himself several feet towards a round table near the sliding glass door. A short moment later, PA2 came out to the lanai and appeared to be conversing with P1. PA2 then left and came back with a cup of beverage and left it on the table for P1. Video then showed PA1 emerging from sliding glass door and in the process of donning rubber gloves. Video appears to show PA1 and P1 speaking to eachother. Not long after, P1 is seen throwing the cup of beverage at PA1. It was then PA1 was seen in the video to lunge at and punch P1 in the face before grabbing P1 by the head/hair and pulling P1 towards the ground. In the video, it appears PA2 was attempting to pull the wheelchair out from underneath P1 (It was confirmed later during interview with PA2 that PA2 was attempting to remove the wheelchair so P1 doesn't get injured or trapped by the wheelchair). After taking P1 to the ground, PA1 then proceeded to place his right knee on P1's head. Moments later, PA1 was seen pulling on P1's hair and dragging P1 several feet and in the process turning P1 from prone to supine position. By then, charge nurse (CN) was seen in the video with the mega mover (canvas gurney) in hand. PA1 was seen squatting next to P1 and they appeared to be conversing. In the video, a SO was seen standing against the wall adjacent to the sliding glass door. It appears the SO was present when PA1 was pinning P1's head with his knee. The video continues to show P1 was placed on the mega mover with PA1 pulling on P1's hair and roughly pushing P1's upper torso down towards the ground. Video clearly showed staff (PA2, SO) were present at the time of the assault and did not attempt to intervene by stopping PA1 or having him removed from the situation or the area.

On 11/15/19 at 12:52 PM, interview with CRMO who stated the video dated 09/22/19 of the incident is very traumatic. CRMO said it was a bad situation of an assault by staff (PA1) on a patient (P1) in the BHU. CRMO said she saw the video the following morning 09/23/19 and requested the BHU staff involved to prepare their statements regarding the incident. CRMO stated she then sat down with each staff to review their statements of the event that took place. CRMO when queried whether she felt the staff involved in the incident responded appropriately to the situation at hand, CRMO stated firmly, "No, I do not." CRMO stated they (facility) are looking into more education and training for staff, not just for staff in the BHU but the facility as a whole.

On 11/15/19 at 07:38 AM, interview with PA2 who stated he did see the video dated 09/22/19 related to the incident. PA2's statement regarding the incident generally mirrored what was seen in the video. PA2 stated PA1 was supposed to be assisting P1 out of bed that morning but because P1 was already irritated at PA1, PA2 was asked by PA1 to get P1 out of bed. PA2 stated P1 was loud and yelling, it was decided to have P1 go out to the lanai so P1 would not disturb other patients who were still asleep. PA2 said as he was pushing P1 out to the lanai, P1 and PA1 were exchanging words with P1 threatening PA1 saying "If I had a gun, I would shoot you." PA2 stated P1 and PA1 were swearing and flipping eachother off with hand gestures. PA2 stated he had noticed P1 who was now out in the lanai was still having interaction with PA1 through the sliding glass door. PA2 said he was going back and forth from the lanai to the nurse's station because he had to give P1 the requested beverage and also inform P1's nurse about what was happening. PA2 stated P1's nurse told him he was already in the process of getting P1's medications ready. PA2 said when he got back out to the lanai, he heard PA1 saying something like "Don't throw that tea at me" to P1. PA2 said he then heard PA1 say "You better not throw that at me." But when P1 threw the tea at PA1, that's when PA1 reacted in a "Violent way." PA2 said PA1 hit or like punched P1 in the face and was pulling P1 off the wheelchair and down to the ground. PA2 said he was in shock and all he could think of was to attempt to remove the wheelchair so P1 doesn't get injured since he was unable to secure P1 back into the wheelchair. PA2 admitted he froze in shock and did not attempt to intervene. PA2 confirms SO was present at the time. PA2 stated he feels adequate and effective working in the BHU even though with not much training but could use some training and learn another technique on how to de-escalate similar situation in the future.

On 11/15/19 at 09:38 AM, interview with charge nurse (CN) who stated he has been working in BHU night shift for 20 years. CN stated he is aware of the incident on 09/22/19 at around 07:00 AM which turned out to be an assault on P1 by PA1. CN stated he did not see the video of the incident because "I have no interest in seeing violence." CN stated he only knew the details about the incident/assault from co-workers talking about it. CN denied knowing or seeing PA1 assaulting P1. CN confirmed he heard P1 yelling at PA1 but felt PA2 would be able to take care of the situation because PA2 was already taking P1 out to the lanai. CN stated he was busy at the nurse's station and still hear P1 yelling outside. CN said the next thing he saw was PA2 coming from outside and waving at him. CN stated he looked out and saw P1 on the floor. CN said he quickly grabbed the mega mover and went outside. CN stated he asked what happened and no one said anything except PA1. CN said PA1 told him P1 threw tea at him and did not stop yelling and we need to put P1 in open seclusion room. CN said PA1 stated P1 was fighting with good hand and needed to be taken down to the floor. CN stated he saw P1 had a bleeding mouth, a lump on the forehead, and scrapes on palms and forearms. When queried what he did next, CN stated he got the mega mover and preparing to put P1 on it. CN said he isn't exactly sure who assisted in moving P1 onto the mega mover but by then, day shift staff arrived and assisted. CN stated he was already passed his time to leave which was 07:15 AM and did not have a ride home. CN stated he quickly documented the incident in progress notes and caught a ride home with PA1. CN denied discussing the incident with PA1 while riding home with him. CN admitted he knew from several days back that P1 did not want PA1 to help him. CN said because of that, he would help P1 whenever he was the charge nurse. Queried CN what he did to ensure PA1 will not have contact with P1. CN stated "Honestly, nothing." CN said patients that are not assigned, they all share the work at night. CN admitted after reading the progress notes he wrote regarding the incident on 09/22/19, it was only partially accurate. CN admitted he was told by staff (PA1 & PA2) as to what happened that day. CN concurred he should have wrote in the progress notes he was told by staff as to what happened that day instead of writing as if he witnessed it himself.

On 11/19/19 at 01:00 PM, interview with psychiatrist who confirms he saw the the video dated 09/22/19 of the assault on P1 by PA1. Psychiatrist stated because of this incident, the facility is now in "Damage Control." Psychiatrist stated P1 is a difficult patient to manage and other facilities were not able to care for P1 prior to his admission to this facility. Psychiatrist stated P1 has been threatening and abusive to staff, and at times even threw things at them without provocation. Psychiatrist said P1 agreed to stay in BHU voluntarily/own free will. Psychiatrist stated he did a psychiatric capacity assessment on P1 on 02/05/19 and the result basically showed P1 is capable of making his own decisions. Psychiatrist stated because P1 is an intermediate care facility (ICF) patient who agreed to voluntarily be in the BHU, he (psychiatrist) will only see P1 as needed or per request. When queried by surveyors regarding P1's psychological effects from this incident, psychiatrist stated "Certainly, to some degree traumatized by the assault." Psychiatrist stated P1 has had less outbursts and is more aware and self reflects on his behaviors toward others. Psychiatrist said P1 does not want to "sabotage" the right to remain in the BHU of this facility. Psychiatrist agreed that if staff had more training, it may have been possible to have prevented this incident.

On 11/15/19 at 07:42 AM and 11/19/19 at 10:08 AM, interview with Director of Clinical Services for BHU (DCS-BHU). DCS-BHU stated she was not present on day of incident which was a Sunday. DCS-BHU stated she got an e-mail regarding the incident from house supervisor and saw the video the following day, Monday. DCS-BHU stated they (management) had a debriefing with the BHU staff Monday morning regarding the incident. DCS-BHU stated some of the night shift staff that were involved in the incident may not have been present. DCS-BHU said they discussed options that staff can implement for a difficult patient. DCS-BHU stated they talked about how staff could handle a situation like this better next time it happens. DCS-BHU said they spoke about what each staff should do in a situation like this but did not discuss what a staff should do if they were witnessing a situation like this. DCS-BHU stated the interdisciplinary team (IDT) has determined BHU is the preferred unit for P1 at this time. DCS-BHU stated P1 is in the BHU voluntarily, he is able to sign himself out any time but P1 chooses to remain in the BHU. DCS-BHU when queried by surveyor stated the SO in the BHU is able to put hands-on during a crisis situation, though it did not happen with this incident on 09/22/19. DCS-BHU stated the facility has elected to move away from Crisis prevention Institution (CPI) training and now uses the concept of Techniques for Effective Aggression Management (TEAM) instead. DCS-BHU stated there are two components to the TEAM concept, one is the TEAM Essentials and the other is TEAM Advanced. DCS-BHU said the TEAM training is on-line through Healthstream.com. DCS-BHU stated the BHU staff are required to take the TEAM Essentials training but not the TEAM Advanced training which is the hands-on portion of the TEAM concept. DCS-BHU stated she is not sure why BHU staff are not required to take the TEAM Advanced training but moving forward, the facility will require BHU staff to take TEAM Advanced training. DCS-BHU stated the facility is now putting the TEAM Advanced training requirement for BHU staff in their policy ("Code Gray" Combative Person).

On 11/19/19 at 11:48 AM, RR of policy for "Code Gray" Combative Person (Policy Stat ID: 5333602 and 4066435) reflected a revision (5333602) dated 08/2019 and pending review. The revised "Code Gray" Combative Person policy (Stat ID: 5333602) under section XI. Training: B. "Emergency Department, Behavioral Health, Intensive Care Unit and Hawaii Island Family Health Clinic employees will also be required to complete TEAM Advanced training. The previous "Code Gray" Combative Person policy (Stat ID: 4066435) with effective date of 10/2015 under section XI. "Training," reflected no TEAM Advanced training requirement for BHU staff, only that the facility will have available training sessions for the following: 1) Awareness of nonverbal communication during interventions, 2) Identifying key components involved in paraverbal communication, 3) Identifying different levels of defensive behaviors, 4) Understanding factors which precipitate escalating behavior.

On 11/19/19 at 12:10 PM, RR of policy for "Handling Irate Customers" (Policy Stat ID: 5485825) under section III. Policy: A. "When dealing with an irate patient or visitor, attempt non-physical intervention prior to physical intervention (defending oneself or protecting another person in imminent harm)." Under section IV. Procedure: A. (4)(b) "Call for the department manager, charge nurse, or house supervisor to take control of the situation." (d) "If the situation worsens, activate the "Code Gray" by dialing *06 and begin announcing three times over the phone "Code Gray" and state department and/or room number if known."

11/20/19 at 10:15 AM, interview P1 with assistance from social worker (SW). Conversation with P1 regarding incident on 09/22/19 reflected P1 had episodes of clarity. P1 stated on day of incident, PA1 was giving him the "finger" underneath his jacket. P1 said he had tea with him but was not hot. P1 stated PA1 was marching towards the door (sliding glass door leading to the lanai) in a "rage-like look." P1 said "He zeroed in on me and coming to get me." P1 stated he tried to put tea on table, everyone made a bigger deal of the drink versus me. During the interview P1 was rambling and difficult to interrupt for any questions. P1 stated he remembers being dragged to the ground by his hair and knee to the head by PA1. P1 stated he was scared and worried about his neck getting more injured than it already is. P1 would talk about this incident but starts talking about another incident and possibly referring to yet another incident. It was difficult at times to decipher which incident P1 was talking about. But one thing was clear, P1 specifically remembers PA1 dragging him down to the ground, PA1 then placed his knee on his head, and dragged him by his hair. P1 stated the whole time, he was scared for his neck because he already has neck injuries. P1 questioned the status of the police investigation and was redirected to the SW for his questions. P1 denies the facility formally interviewed him regarding this assault incident on 09/22/19.

On 11/20/19 at 09:06 AM, interview with SO who was present on day of incident. SO stated he has been working not as a regular but as a part time security officer for this facility for the past 10 years. SO said this was not his regular site, hospice was. SO said on day of incident, he was standing outside P1's room because P1 was loud, belligerent, and using abusive language while staff were caring for him. SO stated P1 was then transported in his wheelchair by PA2 to the lanai. SO stated enroute to the lanai, P1 and PA1 were exchanging foul and abusive language with eachother. SO said at one point, he distinctly heard PA1 telling P1 "Oh yeah! You remember what happened the other day, eh?" SO stated he did not inform staff or anyone else about the comments PA1 made or the heated exchange the two (P1 & PA1) were having. SO stated he was sitting in the day area when PA2 came and requested he open the quiet room because they were going to put P1 in the open seclusion room because P1 was getting too loud and disturbing other patients. SO was queried who makes the decision as to when a patient goes into the open seclusion room. SO stated he doesn't know but thinks the PAs are allowed to. SO said after unlocking and checking the quiet room which is used for open seclusion, he came out and saw PA1 heading for the lanai. SO said a moment later, he saw liquid flying through the air, PA1 grabbing P1's head and pulling P1 off the wheelchair and to the ground. SO said he headed towards the sliding glass door leading to the lanai and found PA1 had P1 pinned to the ground. SO said he did attempt to intervene by telling PA1 to "Stop! Stop!" but with all the commotion and exchange of profanity between PA1 and P1; PA1 did not hear him. SO stated he was in shock and did not think of intervening again or to separate PA1 and P1. SO stated he did not call for a "Code Gray" because his radio was inside the nurse's station and that's the way its always been. SO agreed that maybe he could and should have done more in that situation but was not instructed by the facility as to how to handle that kind of situation. SO stated "I can see we need more hands-on training."

On 11/20/19 at 12:12 PM, interview with Chief Nursing Officer (CNO) who confirms they had a debriefing with the BHU staff the next morning (09/23/19, Monday) regarding the incident on 09/22/19. CNO stated that Monday after the incident, administrative staff huddled to discuss interventions and plans for a situation like this going forward. It was also decided at that time, the CRMO will be the person to work with P1 regarding this incident and to give feedback. CNO stated in his view there may have been some "Disconnect with the IDT." CNO stated everyone may not have been on the same page in relation to implementation of education and training for staff. Which is why when surveyors queried department heads whether security officers are allowed to put hands-on in a crisis situation, some department heads will say yes and some say no. CNO stated he is fully aware of the documentation by the CN in the electronic medical record (which is a legal record) for P1 regarding the incident on 09/22/19 is not completely accurate. CNO stated he has viewed the video of the incident and it does not match what the CN wrote in his notes. CNO said moving forward, they will have more training and in-servicing for facility staff to provide good and accurate documentation.