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Based on interviews with staff, a facility tour, medical record reviews, and review of hospital policies, procedures, and documents, it was determined that the hospital failed to protect and promote the needs of each patient in accordance with acceptable standards of practice.

Findings include:

1. The facility failed to ensure that every patient's need to receive care in a safe setting was provided. (Cross refer to Tag A-1081)

Based on staff interviews, review of four (4) medical records (#1, #2, #3, and 4), and review of facility policies, procedures, and documents, it was determined that the hospital failed to protect and promote the safety needs of each patient by implementing a protocol to address staff response to emergency situations involving assaultive/aggressive patient behaviors, when verbal de-escalation interventions fail.

Findings include:

Reference #1: Facility policy and procedure titled, "Security Management" states: "Policy: ... . The purpose of this security management policy is to establish security management controls and procedures designed to prevent workplace violence... . Procedure: A. Management Commitment and Employee Involvement. 1. The ABH [AtlantiCare Behavioral Health] Safety Officer is responsible for developing, implementing, and monitoring ABH's Security Management Program. ... . employees are responsible for: ... . Participation in continuing education which covers techniques to recognize escalating agitation, assaultive behavior, and discuss appropriate responses. ... . C. Hazard and Prevention Controls: ... . 5. ... . c. Ensure adequate and properly trained staff for identifying and de-escalating crisis situations. ... . D. Training and Education: 1. All employees will be trained on the concept of "Non violent Crisis Prevention Intervention", i.e., that violence should be anticipated, but can be avoided or mitigated through preparation. Staff are instructed to limit physical interventions in workplace altercations, whenever possible. ... ."

Reference #2: Facility policy and procedure titled, "Response to Emergency Situations Assaultive or Threatening Behavior in Office Security" states: "Policy: It is the policy of AtlantiCare Behavioral Health (ABH) to establish procedures to be followed in all ABH units relative to the response by staff to emergency situations regarding assaultive or threatening behavior of clients, staff, or visitors. These procedures will be designed to provide for an effective response to protect the safety and security of our clients, staff, and visitors. ... . Procedure: 1. When a client is assessed to be at risk for immediate aggressive behavior by staff, the following steps are to be taken: a. Appropriate verbal intervention aimed at de-escalating potential for aggressive behavior. b. If (a) above is not effective, leave the treatment room in order to obtain assistance and ensure safety. If other staff and clients are at risk, supervise their leaving the immediate area, if possible. ... ."

1. On 2/3/2022 and 2/4/2022, staff interviews revealed the following:

a. On 2/3/2022 at 9:55 AM, Staff #1 confirmed that a patient-on-patient assault (Reportable Event) occurred at the facility grounds outdoors, on 2/1/22, which resulted in a patient hospitalization. Patient #2 reportedly assaulted Patient #1. Staff #4 and Staff #5 were the first staff responders to the scene. The Police were contacted and conducted their interviews and investigation.

b. On 2/3/2022 at 10:15 AM, Staff #4, an R.N. (Registered Nurse) stated that on the morning of 2/1/22, he/she was notified by Staff #7 that Patient #1 and Patient #2 were outside in the Patient Break Area fighting. As he/she was making his/her way outside, Staff #11 made a verbal announcement that all staff were needed outside. Staff #6 called 911 and multiple staff pressed the Panic Alarm system to illicit an emergency response. Staff #5 reportedly arrived and responded alongside Staff #4. When both staff approached the two patients, Patient #2 was sitting on top of Patient #1. Patient #1 was in the prone position, with his/her face flat to the ground. Staff #4 and Staff #5 asked Patient #2 to get off of Patient #1. Patient #2 refused and stated that he/she would not be getting off of Patient #1 until the police arrive. Patient #2 stated that Patient #1 had hit him/her and he/she did not want to be hit again. Staff #4 said it appeared that Patient #2 had sustained an injury to his/her left eye. Staff #4 further stated that Patient #2 had a grip on Patient #1. Staff #4 and Staff #5 repeated several times asking Patient #2 to get off Patient #1 and release his/her grip. Staff #4 stated that he/she could hear and see that Patient #1 was struggling to breathe. Staff #18 arrived and also asked Patient #2 to remove himself/herself from Patient #1. Patient #2 released Patient #1 when the Police and EMS (Emergency Medical Services) arrived. Patient #1 was turned from prone (face down) to supine (face up) and Patient #1 was not breathing. Staff #4 reveals that he/she has been trained in CPI Non-Violent (Crisis Prevention Intervention Training) yearly and CPR (Cardiopulmonary Resuscitation) every two years. He/she indicated that the facility guidance is to use verbal de-escalation techniques when responding to situations such as this, and that they are not taught nor expected to put hands-on patients.

c. On 2/3/2022 at 11:05 AM, Staff #1 stated that following the patent-on-patient assault on 2/1/2022, Patient #2 left in police custody and Patient #1 was taken to the Trauma Hospital.

d. On 2/3/2022 at 11:15 AM, Staff #5, a S.W. (Social Worker) stated that he/she responded after hearing Staff #11 call out that help was needed in the "patient smoke area," which is the break area for patients. The facility does not use a code system to announce emergencies. The method to communicate emergencies is through a verbal announcement. When he/she arrived, along side Staff #4, Patient #2 was holding Patient #1 down. Patient #2 was sitting on top of Patient #1, and Patient #1 was prone (face down) on the concrete. Patient #2 was asked several times to remove himself/herself from Patient #1. Staff #4 and Staff #5 yelled out for 911 to be called and the panic alarms were pushed. Staff #5 further stated that in their yearly CPI Training, their staff are taught to respond to these type of situations verbally and that they are "hands off."

e. At 11:45 AM, Staff #1 further stated that there were two (2) patients that had partially witnessed the incident (Patient #3 and Patient #4). Patient #4 alerted the staff in the building that Patient #1 and Patient #2 were fighting in the outdoor break area. He/She notified Staff #7 (Mental Health Associate) and Staff #10 (Mental Health Associate). In addition, Staff #1 explained their staff are not trained to restrain patients nor to separate patients with their hands. This incident is the first time an incident of this seriousness has occurred in the time frame of the six (6) plus years he/she has worked for this facility.

f. On 2/4/2022 at 10:05 AM, Staff #3 stated that safety to their staff is paramount. He/she confirmed that there are no policies and procedures in place to address emergency situations where verbal de-escalation techniques fail.

2. On 2/7/22 upon review of Medical Record #1, the following was noted:

a. The document titled, "Trauma Admission H & P [History and Physical]," dated and timed 2/1/22 at 9:19 AM states, "... . History of present illness: This is an unknown (black/white male/female) who arrived to the trauma admitting area this morning as a ground level one (1) trauma alert s/p [status/post] assault. The patient reportedly punched another individual and in turn that person strangled the patient. The patient was reportedly being strangled until police arrived and were able to de-escalate. The patient was found to be in cardiac arrest; CPR [Cardiopulmonary Resuscitation] was initiated and patient had ROSC [Return of Spontaneous Circulation] after about ten (10) minutes. On arrival to the trauma admitting area, the patient was intubated. ... ."

(i) The above document was reviewed from the medical record of the the patient's trauma admission to the Regional Medical Center.

3. The above was reviewed with and confirmed by Staff #1 and Staff #3.

On February 4, 2022, Staff #3 and Staff #15 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A completed IJ template was provided to Staff #3 and Staff #15 via email at 3:45 PM. An acceptable removal plan was provided by the facility on February 4, 2022 at 4:15 PM.

On February 7, 2022, while on site, an assessment was conducted to determine that the facility implemented the IJ Removal Plan. Clinical, Security, and Administrative Staff were interviewed to assess for compliance with the IJ Removal Plan.

1. On 2/2/22, a Security Risk Assessment of the Adult Acute Partial Program and surrounding grounds had been completed.

2. On 2/2/22, the facility administrators took action to establish immediate on-site Security presence at the Adult Acute Partial Program during hours of operation.

3. On 2/3/22, a Security Officer was posted to the Adult Acute Partial Program. On 2/4/22, a plan was implemented to post two (2) Security Officers to this location. Initial notification of emergency situations will occur verbally between staff . Secondary notification will occur through the intercom system. The Security Officers will physically intervene as appropriate, should assaultive events occur.

4. On 2/4/22, a plan was developed based on the Security Risk Assessment recommendations, to mitigate the identified security risks. Security was actively rounding on an hourly basis to assess for safety risks.

5. By 2/7/22, Staff were trained on how to reach security in an emergency situation and on components of heightened awareness of client locations.

On February 7, 2022, at 12:48 PM, it was determined that the IJ removal plan was implemented. The IJ was removed at 1:30 PM.