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Based on interview, record review, policy review, and video review the facility failed to provide a safe environment and protect one patient (#10) of 28 patients reviewed for abuse or neglect when the facility failed to implement immediate measures to remove a staff member (Staff W) from patient care after allegations of abuse were reported. The facility also failed to follow physician orders of placing one patient (#10) on one-on-one (1:1, a continuous visual contact with close physical proximity) monitoring, and failed to appropriately assess the need to place one aggressive and physically violent patient (#11) on 1:1 monitoring, to ensure the safety of other patients and staff.

These deficient practices resulted in the facility's non-compliance with specific requirements found under 42 CFR 482.13 Condition of Participation: Patient's Rights. The facility census was 282 patients with 58 of those patients admitted for behavioral health related care.

After the Centers for Medicare & Medicaid Services (CMS) reviewed the details of the survey, it was determined that the severity of these practices had the potential to place all patients at risk for their safety, also known as Immediate Jeopardy (IJ).

On 05/16/19, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 05/16/19, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Education on the revised 1:1 monitoring policy included the immediate placement of a designated person, without any other duties assigned, with any patient that had been placed on 1:1 monitoring.
- Education on the revised 1:1 monitoring policy began immediately to all clinical leaders and House Supervisors, and they began education to all staff regarding the policy.
- All clinical employees on site and all reporting for the next shift were educated.
- All clinical employees, including as needed (PRN) employees, were educated before their next shift.
- Clinical employees throughout the building would randomly, on each shift, be asked about the appropriate response if a patient was placed on 1:1 monitoring. If less than 100% compliance to these questions then re-education would be given.
- The revised 1:1 monitoring training was added to the new employee orientation and annual training.
- Clinical employees would be provided a questionnaire to demonstrate compliance at new hire orientation and annual training to demonstrate understanding. This information would be kept in the employees personnel file.
- All current patients with assessed needs for and/or orders for 1:1 monitoring were placed on 1:1 monitoring by a designated person that did not have any additional responsibilities.
- Any future patients who expressed behaviors that threatened the safety of self or others would be placed on 1:1 monitoring, and an immediate assessment by a qualified staff member would be completed.
- Qualified staff members who completed the assessments could place patients on 1:1 monitoring immediately and then consult with the provider for written orders.
- Clinical leaders completed audits of any patients who were on 1:1 monitoring to ensure compliance.

Based on interview, record review, policy review and review of video surveillance, the facility staff failed to immediately remove one staff member (Staff W) from patient care after allegations of abuse, of one staff member reviewed for abuse allegations. This had the potential to allow for continued abuse by staff, and could affect all patients. The facility census was 282.

Findings included:

1. Review of the facility's policy titled, "Abuse and Neglect" revised 09/2018, showed that upon witnessing or receiving an allegation of abuse or neglect, facility staff should place any staff suspected to have committed an act of abuse or neglect on administrative leave until a determination of the allegation can be made.

Review of Patient #10's medical record dated 03/19/19 through 04/08/19, showed he was a 69 year old male who was admitted to the psychiatric center.

Review of Patient #11's medical record dated 04/01/19 through 04/07/19, showed he was an 18 year old male who was admitted to the psychiatric center. He had poor impulse control, and was non-compliant with requests to leave Patient #10 alone.

Review of a facility investigation dated 04/07/19, showed that on the morning of 04/07/19 at approximately 11:30 AM, Patients #10 and #11 were in a physical altercation with each other. A code white (code used to prompt help with altercations) was called and Staff W, Mental Health Technician (MHT), responded. Staff W came up behind Patient #10 to remove him, and in the process both Staff W and Patient #10 fell to the ground, hitting the wall first. Patient #10 received a facial laceration and a bloody nose.

Review of the facility's video surveillance dated 04/07/19, from 11:34 AM to 11:36 AM, showed that during the altercation, Staff W came up behind Patient #10 and grabbed him with what appeared to be a bear hug and with forward motion, they both fell to the ground, hitting the wall prior to the fall. Staff W landed on top of Patient #10 and approximately 59 seconds after the fall, got up and released Patient #10.

During an interview on 05/01/19 at 10:00 AM, Staff U, Registered Nurse (RN), stated that on 04/07/19 at approximately 11:30 AM, she saw Staff W have a hold on Patient #10 from behind, with his arms around the patient's waist, and then hit the wall as they fell to the floor. After the physical altercation, Staff W was moved to the other half of the adult male unit, but was allowed to continue working. She felt the approach that Staff W used to separate the two patients was not appropriate and did not follow crisis prevention institute (CPI, training for health care professionals to to provide non-violent interventions while caring for emotionally distraught, disruptive or violent people) guidelines.

During an interview on 05/07/19 at 9:00 AM, Staff W, MHT, stated that:
- After the incident, he was moved to B hall, which is in the same unit but on a different hall.
- He finished his shift on 04/07/19, and left around 7:30 PM.
- He returned to work on the next day, 04/08/19, and worked until around 2:00 PM.
- On 04/08/19 at 2:00 PM, he was told to leave because of an investigation related to the events on 04/07/19.

During an interview on 05/01/19 at 11:30 AM, Staff Y, RN, stated that:
- She felt Staff W was frustrated during the altercation between Patient #10 and Patient #11, and she had instructed Staff W to back off and get up off of Patient #10.
- After the event, Staff W was not sent home, but was moved to work another hall on the unit.
- Staff W had attempted to return to the same hallway after being removed, but she redirected him.

During an interview on 04/30/19 at 12:00 PM, Staff Q, Human Resource Director, stated that as a result of the initial event occurrence on 04/07/19 at 11:30 AM, Staff W was suspended, he had put in his notice after his suspension, but was terminated during his two week notice period on 04/18/19.

During an interview on 04/30/19 at 11:30 AM, Staff E, Interim Chief Nursing Officer (CNO) of the psychiatric center, stated that he did not feel Staff W followed the proper CPI techniques with Patient #10 and was terminated.

During an interview on 05/01/19 at 11:00 AM, Staff J, Risk Management Director and Staff I, Quality Vice President, stated that after review of the video surveillance of the incident, neither of them felt that Staff W had utilized proper CPI techniques, and that they expected the employee should have been immediately removed from the hospital pending investigation. They were under the impression that Staff W had been removed from the hospital after this event, and shared that they were not aware that he had been allowed to continue working on another unit the remainder of his shift, and again on the following day.

The facility failed to implement immediate measures to remove a Staff W from patient care after alleged abuse, and allowed him to continue to work with patients, which could have resulted in the abuse of other patients.

Based on interview, record review, policy review and review of video surveillance, the facility failed to implement protective measures to protect one patient (#10) of 28 patients reviewed for abuse or neglect, after the patient was repeatedly attacked by another patient. This had the potential to lead to unnecessary fear or injury of patients and had the potential to affect all patients in the facility. The facility census was 282.

Findings included:

1. Review of the facility's policy titled, "Abuse and Neglect" revised 09/2018, showed that upon witnessing or receiving an allegation of abuse or neglect, facility staff should ensure immediate protection of the patient.

Review of the facility's policy titled, "Levels of Observation" revised 03/2018, showed:
-One-on-one (1:1, continuous visual contact with close physical proximity) observation is ordered when a patient is at immediate risk of harm to self and/or others;
-The staff member will remain within arm's reach of the patient at all times while on 1:1; and
-The patient will be reassessed each shift for continued need;

Review of Patient #10's medical record dated 03/19/19 through 04/08/19, showed:
- He was a 69 year old male that presented to the Emergency Department (ED) by law enforcement for evaluation and a 21 day hold (court order to remain under psychiatric care for 21 days) for increased aggression and homicidal (thoughts to harm another person) threats after he had brandished (to wave around as a threat) a knife and threatening to harm other people at his nursing home.
- He had a history of paranoid schizophrenia (a mental illness that involves mistaken beliefs that one or more people are plotting against them or their loved ones), with recent exacerbations (increase in symptoms).
- Upon admission to the psychiatric center, the patient was placed on the geriatric psychiatric unit but was quickly moved to the transitions unit (adult male only unit) due to his behaviors.
- During the course of treatment, the patient had frequent verbal outbursts and/or threats to others.
- He was described as verbally antagonistic (showing hostility toward someone), disruptive, verbally sexually inappropriate, intrusive (enter into an area, group or conversation where one is not welcome), and often agitated.
- The treatment team had to redirect him often and use de-escalation (reduction of the intensity of a conflict or potentially violent situation) techniques with the patient which included placing him in reduced stimuli (something which causes a response) environments.
- They had to reinforce healthy communication boundaries with the patient frequently.
- That he was receptive but often did not comply with boundaries.

Review of Patient #11's medical record dated 04/01/19 through 04/07/19, showed:
- He was an 18 year old male that presented to the ED by law enforcement for evaluation and treatment due to erratic, bizarre, and aggressive behavior with his father at home and for suicidal ideation (SI, thoughts of causing one's own death).
- He had a history of psychosis (a disorder characterized by false ideas about what is taking place or who one is) daily drug use, and depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed).
- Upon admission to the psychiatric center, Patient #11 was placed on the transitions unit.
- During the course of his treatment, the patient verbalized that he was angry, he had a recent break up with his girlfriend, and that he was depressed and felt paranoid (excessive suspiciousness without adequate cause) that someone was out to harm him.
- The treatment team worked to avoid seeming suspicious and maintained a calm attitude with patient, using simple and brief messages and low stimuli.
- He was often non-compliant (did not follow the recommendations) with care, refused to speak to staff or answer any of their questions, and was hesitant to participate in group therapies.
- He was described as antagonistic, particularly with other patients, and was fixated on Patient #10 in particular.
- He had poor impulse control, and was non-compliant with requests to leave Patient #10 alone.

Review of a facility investigation dated 04/07/19, showed that on the morning of 04/07/19 at approximately 11:30 AM, Patients #10 and #11 were in a physical altercation with each other. A code white (code used to prompt help with altercations) was called, and during attempts to separate the patients, Patient #10 fell to the ground, hitting the wall first, and sustained a facial laceration and a bloody nose.

During an interview on 05/01/19 at 10:00 AM, Staff U, Registered Nurse (RN), stated Patient #11 had previously hit Patient #10 in the head, that both patients had aggravated each other all shift and that Patient #11 was the main instigator. He would get in Patient #10's face, follow him, enter his room without permission and antagonize him. Staff interventions were to redirect the two men. After the physical altercation at 11:30 AM, Patient #10 was placed on one-on-one (1:1, continuous visual contact with close physical proximity), but Patient #11 was not.

During an interview on 05/01/19 at 11:30 AM, Staff Y, RN, stated that:
- She had witnessed antagonism between Patients #10 and #11, both on 04/07/19 and on prior shifts.
- Patient #10 was hyper verbal and hyper aggressive at his baseline.
- Patient #11 was younger and angry, and was not going to take it.
- She had noticed Patient #11 put a strong focus on Patient #10, and it had caused her great concern.
- She felt something bad would happen between the two patients.
- She had contacted the physician (unsure of his name) for direction after their 04/07/19 altercation at 11:30 AM, and was given orders to place Patient #10 on 1:1.
- Frequently, if orders were received for 1:1 during the middle of the shift, they would not be able to place the patient on the 1:1 until the next shift, because they would not have enough staff to do so.
- On 04/07/19, she and another nurse attempted to trade off and cover the 1:1 for Patient #10 for the remainder of their shift.
- She was not sure why Patient #10 was the only patient placed on 1:1.

During an interview on 04/30/19 at 11:30 AM, Staff E, Interim Chief Nursing Officer (CNO) of the psychiatric center, stated that Patient #10 was placed on 1:1, but Patient #11 was not. Patient #11 had an obsessive focus on Patient #10 and they felt that having Patient #10 on 1:1 was enough to keep Patient #10 protected.

During an interview on 05/07/19 at 9:00 AM, Staff W, Mental Health Technician (MHT) stated that:
- Patient #10 had been verbal and hostile all day on 04/07/19 towards Patient #11 and staff attempted to redirect him, but it did not work.
- Patient #11 was walking down the hallway when Patient #10 punched him and caused a fight between the two patients.
- Neither Patient #10 nor Patient #11 were put on 1:1 during the remainder of his shift on 04/07/19 because they didn't have enough staff to do so.

Review of a facility investigation dated 04/07/19, showed that on the evening on 04/07/19 at approximately 10:00 PM, Patients #10 and #11 had a second physical altercation. Staff #11 entered the day room covered in a blanket and jumped on Staff X, MHT, to get to Patient #10. During that event, Patient #10 was knocked down to the ground, and later complained of pain, guarded his right leg and was non weight bearing. He was transported to the ED where he was admitted with a diagnosis of a right femoral head fracture (a type of hip fracture).

During an interview on 05/01/19 at 10:20 AM, Staff V, RN, stated that at approximately 10:00 PM on 04/07/19 she heard a loud commotion in the day room area. Patient #11 ran towards Patient #10. A staff member in the room tried to prevent the attack, but was unable, and Patient #10 ended up on floor, after he fell backwards. Patient #10 complained of pain and was sent out to the ED. Security had called 911, and police came and took Patient #11 away after he had also attempted to attack security and police.

The facility failed to implement protective measures to protect Patient #10 from Patient #11, who was repeatedly aggressive and physically violent toward the patient.