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A substantial allegation survey was conducted to investigate an alleged violation of the Condition of Participation of Patient Rights at 42 CFR 482.13. North Memorial Health Hospital was found NOT IN compliance with the CoP set forth at 42 CFR Part 482 Subpart B. See A144.

Based on interview and document review, the hospital failed to provide care in a safe setting for 4 of 10 patients reviewed (P1, P4, P4, and P7). P1 when the hospital staff failed to respond appropriately to an instance of patient aggression and failed to assess the patient for violence risk per policy, P3 when staff failed to appropriately reassess a patient for risk of homicidal ideation, P4 when staff failed to assess the patient for violence risk, and P7 when staff failed to initiate an appropriate care plan for a patient at risk for violence and failed to assess the patient for violence risk per policy.

Findings include:

Medical record review revealed P1 was admitted to the hospital on 11/6/19. P1's history and physical dated 11/6/19, indicated diagnoses included para-suicidal behavior (acting out), bipolar affective disorder, hypomania, autism spectrum disorder, intellectual disability, seizure disorder. P1 reportedly kicked staff in the face at his group home, and the group home would not take him back. P1 was actively increasing his behaviors both in terms of the frequency with them, and also in terms of the aggressiveness. This trend has been going on for several weeks (evidence by more frequent admission from group home.)

P1's Psychological Assessment dated 11/6/19, revealed P1 reported he wanted to hurt staff, he feels that way when he does not get what he wants, P1 had a history of damage to property, hitting staff. P1 was brought to the ED by police related to violent outbursts at his facility.

Hospital nursing notes dated 11/18/19, revealed P1 had an episode of violence that included smashing a vase and breaking his TV, yelling at and threatening staff. P1 was restrained by staff.

Although staff had assessed the patient as at risk for violence, they failed to regularly reassess the patient for her violence risk while hospitalized. A review of Nursing Assessment data revealed P1 was reassessed for violence risk only sporadically, and not at all on 11/16/19, 11/19/19, 11/24/19, 12/1/19, and 12/2/19.

During an interview with registered nurse (RN)-I, on 12/2/19, at 11:15 a.m. she stated that she was P1's nurse on 11/18/19, when P1 had a violent outburst. RN-I stated that P1 became upset when he did not get his way, and he became violent, throwing a vase, tried to grab a scissors, and was throwing things out of his room. During the incident most staff ran away to hide from P1 except RN-I and physician R (MD)-R. RN-I and MD-R tried to calm P1 until security arrived to restrain P1. RN-I stated that there has been a recent change, and the unit 2 West, a medical unit, is now housing more psychiatry patients. RN-I stated staff do not feel they have enough training. RN-I stated she was concerned about this, as there is a mix of medical and psychiatry patients on the unit, and is concerned for staff and patient safety.

During an interview on 12/2/19, at 12:20 p.m. RN-N stated she does not feel safe on the unit. She stated the patients who are not mental health patients have told her they are scared of the mental health patients, as they are wandering around the unit. She stated if a patient gets violent it takes security a while to respond. RN-N stated she was told that if a patient gets violent, she should call for help and run for safety. She stated when a patient escalates who has severe mental illness, the staff do not know what to do. Although there was some computer training related to the change (of the increase in the number of mental health patients on the unit), staff do not feel prepared.

During an interview on 12/4/19, at 8:30 a.m. RN-D, Director of Patient Care, RN-X, Nursing Education, and RN-E Regulatory Compliance, confirmed that P1 was not reassessed for violence risk according to hospital policy. RN-D stated they had not reviewed the 11/18/19, incident related to how staff responded (running away to hide from the aggression) to the aggressive patient, and no corrective action had been taken.

Medical record review revealed P3 was admitted to the hospital on 10/14/19, with diagnoses that included homicidal ideation and schizoaffective disorder. P3's history and physical dated 10/14/19, revealed she stated she was afraid she was going to hurt people, was confused, and was verbally threatening, stating she wanted to hurt lots of people. Nursing notes dated 10/24/19, revealed she stated that she would hurt anyone if they tried to hurt her. Although staff had assessed the patient as at risk for violence on admission, they failed to regularly reassess the patient for her violence risk while hospitalized. A review of nursing assessments revealed P3 was not reassessed for violence risk at all on 10/17/19, 10/18/19, 10/19/19, 10/20/19, and was not reassessed per shift as required on the other days of admission, until she was moved to 2 East, the mental health unit. A nursing note dated 10/24/19, revealed P3 stated her hold was up, and she wanted to leave. P3 became aggressive and began yelling.

During an interview on 12/4/19, at 8:30 a.m. RN-D, RN-X, and RN-E confirmed P3 was not reassessed for violence risk according to hospital policy.

Medical record review revealed P4 was admitted to the hospital on 10/6/19, with diagnoses that included bipolar disorder, aggressive behavior, and mild developmental disability. P4's history and physical dated 10/6/19, revealed P4 was brought to the emergency room because he became aggressive with group home staff, throwing a lamp and hitting residential staff, he ran into the road and threw things at staff. Although the patient was assessed on 10/7/19, on admission as having more than 2 risk factors for violence, there was no regular reassessment of P4's violence risk by nursing staff. A review of nursing assessment data revealed the patient was not reassessed for violence risk from 10/15/19, through 10/21/19, and only sporadically on other days. A nursing note dated 10/14/19, revealed P4 became aggressive with staff, and security had to be called.

During an interview on 12/4/19, at 8:30 a.m. RN-D, RN-X, and RN-E confirmed P4 was not reassessed for violence risk according to hospital policy.

Medical record review revealed P7 was admitted to the hospital on 11/7/19. P7's diagnoses included agitation, Alzheimer's disease, and confusion. Nursing assessments dated 11/7/19, revealed P7 had 2 or more risk factors for violence. Although P7 was assessed by staff on admission as being at risk for violence, no interventions for this risk were implemented by staff. A review of nursing reassessment data revealed staff were not regularly reassessing P7 for violence risk. Nursing notes,dated 11/15/19, revealed P7 started yelling and becoming agitated, and security had to be called.

During an interview on 12/4/19, at 8:30 a.m. RN-D, RN-X, and RN-E confirmed P7 was not reassessed for violence risk according to hospital policy, and interventions to mitigate violence risk were not initiated for P7.

During an interview with RN-K on 12/2/19, at 11:50 a.m. she stated she did not feel prepared to care for the number of mental health patients now on the unit. She felt the change was thrown onto staff, and it was concerning because the mental health patients were free to roam the unit, putting the medical patients at risk. RN-K also stated it was concerning because security was not always there, and it would take them awhile to respond when staff called them. She stated many staff were fearful just coming to work. She stated she felt the medical staff from 2 West were just not experienced enough to handle the acuity and number of mental health patients now being sent to the unit.

During an interview with RN-L on 12/2/19, at 12:00 p.m. she stated when the unit transitioned to increase the number of mental health patients, she did not think it would be a big change. However, she stated she did not feel prepared for the acuity of the mental health patients being admitted. She stated she did not think there was enough training, and the unit did not feel safe. RN-L stated recently a patient who was on a hold tried to escape via the elevator. Although staff intervened, there was not always staff watching the elevators. With the mental health patients on the unit, RN-L stated,"You feel like you have to watch your back all the time, and when someone is exploding, you do not always know what to do."

During an interview with RN-M on 12/2/19, at 12:10 p.m. she stated that she does not feel safe on the unit. She stated the unit now has violent, aggressive patients who raise hands at staff, and are aggressive. She stated there are psychotic patients running in the halls, and walking into other patient's rooms. She stated she has had a couple of patients and family members ask if they are on a mental health unit, and they stated they feel unsafe on the unit. Patients have told her they cannot sleep due to the loud screaming on the unit. She stated patients have also tried to escape, and the doors to the unit are not locked. RN-M stated there are six elevators and there was not always staff at the desk to watch the elevators. She stated she feels the medical patients on the unit are at risk because the psychotic patients are unpredictable. She stated she did not feel there was enough education related to the unit change.

The hospital policy titled Assessment and Documentation dated 11/28/18, directed: Admission Navigator 1. a. Screen for problems/conditions which trigger a need for more focused assessments by nursing and/or other disciplines. 3. Complete reassessments based on population specific parameters, customer/family needs, desire for care, response to previous care or treatment or care setting. Under Plan of care: 1. an individualized plan of care and customer education is developed and documented within 24 hours of admission...2. The care plan is reassessed and individualized to the customer once between the hours of 0700-1900 and also 1900-0700 and with condition changes.

The staff training module titled Maintaining a Safe Environment revealed:the plan included 1. Identify at risk behavior, 2. recognize and treat anxiety, 3. Intervene to manage aggressive behavior. Some patients are at higher risk for aggressiveness. At risk medical conditions include, altered neurological status, (dementia), mental health diagnoses, (schizophrenia), and or medical holds, history of assaultive behavior, patients experience manic episodes or recent trauma.