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Based on record review and interview, the hospital failed to ensure 2 of 3 patients (Patient #7 and #8) received care in a safe setting and were protected from harm. Patients #7 and #8 were hit by a peer (Patient #6).

Findings Included:

1) Patients #7 and #8's medical records included on 11/27/11 at 1640 they were watching TV in the day room when Patient #6 became upset about being asked to relinquish the remote control. Patient #6 jumped up, pulled off his shirt, jumped over other patients and hit patient #7 in the face and head. One blow fell on patient #8 when she attempted to intervene.

The nursing note timed at 1700 reflected that patient #7 had a bloody nose and swelling about his left eye. Orders were received to transfer the patient to an acute care hospital emergency room for treatment. He returned later that evening with no intracranial bleeding or fractures. The nursing note at 1700 reflected that patient #8 had "no visible injury."

2) In an interview with the surveyor at 1300 on 02/14/12, Personnel #2 and #3 were asked what happened at the time of the event. They reported that the staff had failed to monitor the milieu of the unit and did not follow facility policy by allowing a patient to have the remote control.

3) In an interview with the surveyor at 1300 on 02/14/12, Personnel #2 and #3 confirmed that patients #7 and #8 were hit by patient #6.