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Based on record review and interview, the hospital failed to prove the patient/grievant with a writtan notice containing the steps taken to investigate the grievance, the results of the grievance process and the da te of completion for one patient (ID #B) of one grievance letter reviewed regarding the assault of the patient.

Findings Include:

Record review of the facility policy "General Grievances and Patient Advocacy" #14962780 dated 01/2024 stated:

Purpose:
To establish a mechanism by which to impartially receive, investigate, review and process patient complaints, patient grievances, and/or in the issue regarding patient rights.

Patient Grievance:
The formal or informal written or verbal complaint that is made by a patient, or the patients representative, regarding the patient's care (when a verbal complaint about patient care is not resolved at the time of the complaint by staff present), abuse or neglect, issues related to the facilities' compliance with the CMS Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations.

A complaint is considered the patient grievance when:
If if it is a complaint that cannot be resolved at the time by staff present, was postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action or resolution.

If the patient complaint cannot be resolved promptly by staff present, information regarding the concern will be provided to the patient advocate to be handled in investigated as a patient grievance. If the patient advocate is not on site, patient advocate designee will initiate the investigative process.

The Patient Advocate or Patient Advocate Designee
1. Most of acknowledge receipt of the patient grievance within 24 business hours of becoming aware of the same.
2. Provides the patient, patient representative and/or family member an opportunity to voice their concerns.
3. Investigates the identified patient grievance and determines the resolution within seven (7) business days, the patient, family member, or patient representative will be notified, in writing by the patient advocate and/or patient advocate designee that the investigation is ongoing, will furnishing a time frame for the expected completion.
4. The patient advocate will modify the patient, family member location representative of the results in writing.

Record review of the grievance letter sent by the Director of Quality (staff ID #1) to patient (ID#B) on 02/25/2024 stated the facility "re-educated the leadership team and staff on the importance of overall communication in addressing families concerns as well as communicating the role they have in providing care".

Record review of the grievance letter sent by the Director of Quality (staff ID #3) to the parent of patient (ID#B) dated 02/25/2024 (1 day after the incident) stated "We our continuing to meet for progressive and actions ensuring lasting change and compliance. Some of these decisions have included, but are not limited to staff trainings an adding new staff... We will continue to share the issues you raised in your complaint with our staff in order to improve our processes and ensure a better experience for all of our patients.

Interview on 03/01/2024 between 3:15 pm and 3:30 pm with both staff (ID#2, and 3) revealed there were no training records regarding assaultive behaviors, their prevention, or a debriefing on what occurred. During an interview 03/04/2024 the Director of Quality (staff ID#2) stated she does the grievance investigations and has 30 days to complete them per policy. She stated she had asked the nursing supervisor what happened and had not investigated further.

During observation of film on 03-04-2024 at 1:00 p.m. with staff #2 Director of Quality and Staff #3 Chief Nursing Officer of an adolescent unit attack on 02/24/2024 showed patient #B being quickly approached and kicked and punched by patients #s C, D, E and F as patient #B sat on the floor, both staff #2 and #3 stated they had not seen the film and did not know which patients were which in the attack without a floor staff identifying the patients during the review.

Based on observation, interview, and record review, the facility failed to ensure 5 of 17 sampled patients were free from all forms of abuse or harassment (Patient ID#s B, C, D, E, F and G).

The facility failed to ensure:

1. Patients were placed on appropriate safety precaution levels based on current observation and documented patient history (Patient # C, D, E, F); and
2. Staff understanding of precaution levels was consistent with facility policy.

Findings include:

Review of facility policy #13048351 titled " Levels of Observation and Precautions" last revised 02/2023, read:

Purpose:

To ensure there is a clear differentiation between patients' needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior.

Policy:

Nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level process and findings and patient behavior.

It is critical that patient observation level and precautions are documented as on the Close Observation Sheet and communicated to to members.

Aggression Precautions:

All patients scoring 3 or higher on the Broset Violence Checklist (BVC) or nursing identifies to be at high risk or aggression/violence must be placed on Aggression Precautions.

Immediately initiate an order for Aggression Precautions, including required interventions and additional patient specific individualized interventions. Required interventions below:

1. Continue BVC Assessment the times daily
2. Monitor behavior signs of aggression closely so there is a lower threshold to offer medication or intervene.
3. If aggression is focused on the selected patient or staff member, separate by wing or unit
4. Often use of empty room, group room, or calm/empty room to assist in reducing additional stimuli in patient escalates or becomes agitated.
5. Room easily visible from lounge area for nurses station.
6. Consider use of exercise equipment as an outlet for aggression.
7. Engage patient in treatment planned development or focusing on precipitating factors, coping skills, and anger management.
8. Private room if not on an increased level of observation, as clinically indicated.
9. Consider creating an individually specific behavior plan to mitigate potential violence.

Review of a physician order, dated 10-16-18 (1600) for Patient # 3 read: "suicide precautions..."

Observation of film on 03-04-2024 at 1:00 p.m. with staff #2 Director of Quality and Staff #3 Chief Nursing Officer of an adolescent unit attack on 02/24/2024 showed patient #B being quickly approached and kicked and punched by patients #s C, D, E and F as patient #B sat on the floor. Patient C was the instigator. The attack stopped before staff were able to intervene. Patient B was immediately moved to another unit and discharged Against Medical Advice (AMA) with her parent that same day.

Record review 03/01/2024 revealed patients C, D, and E were not on Aggression precautions.

When interviewed 03/04/2024 at 12:20 pm Staff #9, patient C's psychiatrist confirmed they had not been placed on Aggression Precautions after the attack. He stated he had not been made aware the attack occurred. He stated Patient C had voiced homicidal ideations on 03/04/24 during their visit. The patient expressed wanting to get a gun and shoot his social worker for "Snitching" on him and since he did not have a gun in the hospital he would "Kick the @*!!" of patients that made him mad. Patient C informed the psychiatrist he had coerced the other patients to participate and plan the attack.

When interviewed 03/04/2024 at 3:40 pm staff #1 CEO stated patients # C, D, and F had attacked a different adolescent over the weekend (exact date not provided) to and police were called deescalate the aggressors. He stated they required the use of handcuffs.

There was no evidence of any interventions taken for the aggressors after the first attack by patient #C on 02/24/2024 to possibly prevent a second attack that occurred on the weekend of 03/03/2024.