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Based on observation, interview, and record review, the hospital failed to protect and promote patients' rights as evidenced the hospital failed to ensure patients received care in a safe setting, when they failed to appropriately address Patient 1's use of substance abuse the day before admission, his paranoid thoughts towards Patient 2, and intervene to prevent physical abuse of Patient 2.

The cumulative effect of these systemic practices resulted in the hospital's inability to provide high quality healthcare in a safe environment, therefore, the hospital was found to be out of compliance with the Condition of Participation for Patient Rights. Cross reference to A 144.

Based on interview and record review, the hospital failed to provide care in a safe setting for two patients (Patient 1 and 2), when nursing staff failed to provide safe environment and adequate supervision.
This failure resulted in Patient 1 physically assaulted Patient 2 unprovoked, and unwitnessed by staff, until Patient 2 was found unconscious, which resulted in Patient 2's emergency hospitalization at another acute care hospital, in critical condition. Patient 2 was admitted with Glasgow Coma Scale level 3 (scoring system for brain injury, where GCS 8 or less is classified as Severe) with head trauma and fracture of the left zygomatic arch bone (bone located on the middle of the face), and subaracnoid hemorrhage (bleeding in the space between brain and the surrounding membrane). Patient 2's status continued to deteriorate. Subsequently, Patient 2 remained in the acute care hospital until his death on 2/8/20 (8 days after the physical assault).

The failure of the facility to ensure patients were free from physical abuse resulted in a serious and immediate threat to the health and safety of all patients and placed them at risk of serious injuries.

Findings:

Review of the facility's policy and procedure (P&P) titled "Rights and Responsibilities of Patients," reviewed on 6/2017 showed in part, "a patient has the right to receive care in a safe setting, free from verbal or physical abuse or harassment. The patient has the right to access protective services including notifying the government agencies of neglect or abuse."

Review of the facility's P&P titled "Use of Sitters," reviewed on 10/2019, indicated in part, the purpose of the policy is to meet the needs for patient safety.
Patient sitters will be assigned to patients when the patient meets specific criteria for constant observation. The Nursing Officer/Nursing Supervisor or Charge Nurse will assign patient sitters as needed.
Under Procedure, the policy indicated in part, the Criteria for assignment of patient sitters include any or all the following:
1. At constant risk for harm to self/others (suicidal/homicidal).
2. Rapid/unexpected (up to 48 hours) change in mentation with significant, continuous confusion/disorientation.
The Nursing Officer/Nursing Supervisor or Charge Nurse will use the following guidelines for obtaining staff to function in the role of patient sitter:
1. They will assess the situation for the skill level needed.
2. If unable to staff this position, they will assess current in house resources by assessing current nursing units, acuity, and staffing levels. Staff will be transferred to fill this immediate need to ensure patient safety.

Review of the facility's P&P titled "Assessment and Re-Assessment of Patients," reviewed on 4/2018, showed in part, each patient is reassessed at regularly specified times related to the patients course of treatment, to determine the patient's response to treatment; when a significant change occurs in the patient's condition; and when a significant change occurs in the patient's diagnosis.

On 2/18/20, an unannounced visit was made to the facility to investigate a complaint allegation that occurred when Patient 1 assaulted Patient 2 on 1/31/20.

On 2/18/20, the clinical records for Patient 1, and 2 review was initiated.

A review of Patient 1's medical record showed he was a young adult male, who presented to the Emergency Department (ED) on 1/30/20, at 1:48 PM.

A review of Patient 1 ED History and Physical (H&P), dated 1/30/20, electronically signed at 6:37 PM, showed the patient was brought in from the sheriff station complaining of left foot pain and left wrist pain. He was lethargic and rambling saying he had amnesia. The section for ED Course/Medical Decision Making showed Patient 1's had diagnoses of Rhabdomyolysis (a condition in which damaged skeletal muscle breaks down rapidly), altered mental status, extremity pain, and muscular pain.

Review of the ED physician's orders dated 1/30/20, at 5:20 PM, showed a laboratory order for Urine Drug Screen (U Drug Scr, to determine if the subject has been using the drug) STAT (immediate response).

Review of the clinical record failed to show documented evidence the ED nursing acted upon the physician's orders for urine drug screen and for Urine Analysis by collecting and sending them to the laboratory.

During a review of Patient 1's "Psychiatric Emergency Team Assessment" (PETA), dated 01/30/20, the "PETA" showed, Patient 1 had a history of methamphetamine addition (powerful, highly addictive stimulant that affects the central nervous system), homelessness, and bipolar (is a brain disorder that causes unusual shifts in mood, energy, activity levels). The PET assessment showed Patient 1's mental status was lethargic, depressed, and hopeless (lack of hope).

Review of the physician's order dated 1/30/20, at 6:34 PM, showed an order to admit Patient 1 to Medical Surgical/Telemetry unit.

Review of the H&P for Patient 1 dated 1/30/20, electronically signed on 2/2/20, at 9:18 PM, showed under the physicians Assessment/Plan for Rhabdomyolysis was vigorous hydration, for the altered mental status, the plan was neurology evaluation, and for psychosis the plan was psychiatric evaluation. However, there was no physicians order for psychiatrist consult until after Patient 1 assaulted Patient 2.

A review of Patient 2's medical record showed he was an elderly male who presented to the ED on 1/30/20, at 11:58 PM, with chief complaint of "changing in mental status, including slurred speech." Patient 2 was admitted to Medical Surgical/Telemetry unit, with diagnoses that included severe sepsis (generalized infection) secondary to Urinary Tract Infection (UTI). Patient 2's shared the same room with Patient 1.

Review of the Progress Note Non-Physician dated 1/31/20, at 8 AM, showed Patient 2 was alert and oriented times three: person, place, time, but not situation.

On 2/18/20, at 11 AM, tour rounds to the Med/Surg Telemetry Unit was conducted, accompanied by the Med/Surg Telemetry Manager. Observation of the Patient 1 and 2 room was conducted. The room was located next to the emergency door, before the elevators, about 5 rooms away from the nurses' station.

Review of Registered Nurse (RN 1-Patient 1's primary nurse) Progress Note Non-Physician dated 1/31/20, showed the following:

At 8:23 AM, Patient 1 stated, "Nurse, nurse, I heard the guy next to me yell "Reggie, Reggie!" RN at bedside, did not hear patient in next bed yell out patient's name. Patient appeared to have paranoid thoughts. Comforted patient that he is in a safe place and that he is being monitored. Will keep monitoring patient's behavior. Suggested sitter (one to one sitters are responsible for continuous observation in order to prevent injuries to high-risk patients) for patient to Charge Nurse (CN).

At 9:24 AM, phlebotomists attempted to draw patient's [Patient 1] blood at bedside, patient cooperated. However, changed his mind and refused. Patient stated "get out of my room."

At 10:15 AM, RN found patient [Patient 1] resting in bed with his eyes closed, but easily arousable. Patient 1 stated "He (Patient 2) was trying to rape me." Patient 1 was reoriented he was in a safe place, and that he was at hospital. Patient 1 did not exhibit any threatening behavior at this time. Will keep monitoring.

At 10:45 AM, showed in part, "tried to get history from patient [Patient 1], unable to recall past medical history but admits to meth (crystal methamphetamine, a strong and highly addictive drug that affects the central nervous system) use yesterday."

At 11:22 AM, was informed Patient 1 had punched Patient 2. Patient 2 was found unconscious and snoring. Patient 1 was removed from the room and temporarily moved to another room with a sitter at bedside.

At 11:30 AM, upon arrival to room with sitter, Patient 1 admitted he punched Patient 2 because "He was trying to crawl in bed with me and trying to rape me." Patient 2 stated he had punched the patient "many times" with his left hand. Sitter at bedside and will continue to monitor patient.

At 1:53 PM, Patient 1 was placed on 5150 hold (refers to the California law code for the temporary, involuntary psychiatric commitment of individuals) for being danger to others. "Collected urine drug screen."

Review of the General Chemistry showed urine sample was collected on 1/31/20, at 1:53 PM. The results showed "positive for Urine Amphetamine screen."

Although RN 1, on duty identified Patient 1 had used substance abuse the day before, and was having paranoid thinking (defined as persecutory, or beliefs of conspiracy concerning a perceived threat) towards Patient 2, and needed monitoring, she did not develop a care plan with interventions, including a method of monitoring or supervision, specific frequency, and level of supervision, to ensure other patients were not subjected to Patient 1 possible physical assault.

During an interview with RN 1 on 2/18/20, at 12 PM, she confirmed she did not develop a care plan to address monitoring/level of supervision. When asked what the Charge Nurse (CN) response was when she suggested sitter for Patient 1, she stated the CN stated they could wait until another patient to be discharged to use the sitter.

During an interview with the Med/Surg Telemetry Manager on 2/18/20, at 1 PM, she reviewed of the Med Surgical Unit Staffing dated 1/31/20 for shift 7A (day shift/12 hours). She stated the census was 29 patients. After reviewing the staffing assignment, she stated there were two sitters available to be used if needed, one was assigned to be a "relief," and another sitter was available to come to work, on call basis. She stated she doesn't know why they were not utilized to stay with Patient 1, on one to one.

During an interview with the CN on 2/18/20, at 1:25 PM, she stated she remembered Patient 1 was weird, and hallucinating. She stated RN 1 mentioned about placing the patient on one to one, but she was waiting one patient to be discharged. She stated she did not pulled out the sitter from the floor, or called the one on call, because Patient 1 did not have the behavior of being aggressive, verbally abuse or was throwing things. However, there was no documentation found in the medical records to show the CN assessed Patient 1 to determine if Patient 2 (elderly, vulnerable patient) was safe.

During an interview with the Director of Med Surg Tele, on 2/19/20, at 1255 PM, she confirmed the urine drug screen was not performed and the issue with the sitter. She stated if they knew the patient was positive for Amphetamine, which would make a difference, we could have been expecting a drug withdrawal behavior, such as aggressively or hallucinations.

During an interview with the Chief Nursing Officer (CNO) on 2/19/20, at 12:30 PM, she stated the incident was a complete act of violence. She confirmed there were two sitters available, but it was the CN judgement to wait another a patient to be discharged first. She stated the CN did not assess Patient 1 need for a sitter. She confirmed there was no care plan developed to address Patient 1's supervision.

Review of Patient 2's Progress Notes dated 1/31/20, showed "... House Resident Staff ... found patient bleeding from left ear. Paged nursing station to come see patient. Assessed patient with team. Patient semi-flowers position (positioned on their back with the head and trunk raised), blood dripping down face from left ear, and unarousable to voice, touch and pain. Observed hematoma forming at left forehead. Pupils pinpoint. During assessment patient roommate (Patient 1) ... screams "I hit him because he tried to come into my bed." When asked to repeat what he said; roommate ... stated "Yeah I hit him!" (With fist clenched). Charge nurse notified and patient was removed from the room ... a rapid response was called at 11:30 AM. ICU team and ICU attending arrived at bedside ..."

Review of Patient 2's Rapid Response Team Assessment Flow Sheet dated 1/31/20, at 11:30 AM, showed Patient 2 had eye abrasion with bleeding and was found unresponsive. He was transferred to the Intensive care unit.

Review of documentation titled "Final Report" dated 1/31/2020, at 11:22 AM, showed the student nurse indicated that Patient 1 punched Patient 2. Patient 1 was removed from the room (after the physical assault). At 11:30 AM, Patient 1 was assigned a sitter.

Review of the computerized tomography (CT) scan (combines a series of X-ray images) of Patient 2's head dated 1/31/20, showed the patient had suffered an intracranial hemorrhage (bleeding) near to the basal ganglia (part of the brain) the right side."

Review of a Psychiatric Consult report dated 1/31/20, electronic signed at 3 PM, (after the physical assault) showed "...the patient had an aggressive combative outburst where patient struck and hit another patient...is responding to internal stimuli...endorses auditory hallucinations...endorsed having suicidal ideations...the patient is agitated, restless and labile...disorganized...reports being on regimen of Depakote (medication used to treat manic episodes associated with bipolar disorder), Zyprexa (antipsychotic medication), and Cogentin (medication used to treat involuntary movements due to the side effects of certain psychiatric drugs) previously...reports not taking the medications approximately two weeks...A toxicology screen is not currently available...Diagnoses Schizoaffective disorder, bipolar type (is a mental health condition that includes features of both schizophrenia and a mood disorder)... urine toxicology screen will be obtained."

Review of a Neurology Consult Note dated 1/31/20, electronically signed at 2:55 PM, (after the physical assault) showed Patient 1 was positive for Meth, and admitted to stopping his psychiatric medications and going on a "methamphetamine binge for two weeks." Confusion and Altered Mental Status (AMS) likely secondary to chronic psychiatric illness combined with acute methamphetamine psychosis.

Patient 2 required to be hospitalized at another acute care hospital (Hospital 2) on 1/31/20, at 2:18 PM, in critical condition. Review of Hospital's 2 documention showed a "Pulmonary and Critical Care Consult," dated 1/31/30, at 3:03 PM, Patient 2 was admitted with diagnosis of traumatic subaracnoid hemorrhage (bleeding in the space between brain and the surrounding membrane), Glasgow Coma Scale level 3 (scoring system for brain injury, where GCS 8 or less is classified as Severe) with head trauma and fracture of the left zygomatic arch bone (bone located on the midle of the face). Documentation showed Patient 2 at baseline, per transfer physician, is alert and oriented times four, ambulatory, and independent with Activities of Daily Living (ADL).

Patient 2's status continued to deteriorate. Subsequently, Patient 2 remained in the acute care hospital until his death, on 2/8/20 (8 days after the physical assault), after placed on comfort measures.

During an interview with Chief Executive Officer (CEO) on 2/19/20, 12:30 PM, he reviewed the records and confirmed there was no Urine Drug Screen results in the records prior to inpatient admission, the hospital, staffing and sitters were available, but were not used, failure to appropriately address Patient 1's behavior and intervene to prevent abuse of Patient 2.

Based on interview and record review, the hospital failed to ensure an Emergency Department (ED) registered nurse (RN) followed their policies and procedures (P&P) when the physician's orders were not carried out for one patient (Patient 1).This failure created the increased risk of substandard care provided to the patients.

Findings:

On 2/18/20 the clinical records for Patient 1 review was initiated.

Patient 1 presented to the Emergency Department (ED) on 1/30/20, at 1:48 PM, he was brought in by ambulance, from the Sheriff's station, with a chief complaint of "walking a lot and complaining of left foot pain and left wrist pain."

Review of the ED physician's orders dated 1/30/20, at 5:20 PM, showed a laboratory order for Urine Drug Screen (U Drug Scr, to determine if the subject has been using the drug) STAT (immediately.)
Another physicians order dated 1/30/20, at 5:20 PM, showed an order for Urine Analysis Macro (direct visual observation of the urine, noting its quantity, color, clarity or cloudiness, etc.) STAT.

During a review of the facility's policy and procedure (P&P) titled, "Test Turnaround Time," dated 01/2018, the P&P indicated, "... Stat Order... Result available within 1 hour of receipt of specimen in laboratory..."

Review of the clinical record did not show documented evidence the ED nursing acted upon the physician's orders for urine drug screen and for Urine Analysis by collecting and sending them to the laboratory.

Review of a physician's order dated 1/30/20, at 6:34 PM, showed an order to admit Patient 1 to Medical Surgical/Telemetry unit.

Review of Registered Nurse (RN 1-Patient 1's primary nurse) Progress Note Non-Physician dated 1/31/20, at 11:22 AM, showed she was informed Patient 1 had punched Patient 2. Patient 2 was found unconscious and snoring. Patient 1 was removed from the room and temporarily moved to another room with a sitter at bedside.

Review of the Progress Note Non-Physician, entered by RN 1 dated 1/31/20, at 1:53 PM, showed Patient 1 was placed on 5150 hold ( refers to the California law code for the temporary, involuntary psychiatric commitment of individuals) for being danger to others. "Collected urine drug screen."

Review of the Lab View for Urinalysis-Macro showed it was collected on 1/31/20, at 1:53 PM (after the physical assault) .

Review of the General Chemistry showed another urine sample was collected on 1/31/20, at 1:53 PM. The results showed "positive for Urine Amphetamine screen."

During an interview with RN 1, on 2/18/20, at 12 PM, she confirmed the nursing staff in the ED did not carried out the physician's orders for Urine Drug Screen, and Urine Analysis. She stated would make a difference in the patient's room assignment, the patient could be in methamphetamine (is a powerful, highly addictive stimulant that affects the central nervous system) withdrawal, which symptoms include psychosis (condition that causes losing touch with reality).

During an interview with the ED Director on 2/19/20, at 12:45 PM, she stated "I have no idea why they did not get it, because they did not document anything."

During an interview with Chief Executive Officer (CEO) on 2/19/20, at 12:15 PM, and also with the Director of Performance Improvement & Risk Management at 1 PM, they reviewed the records and confirmed there was no Urine Drug Screen results in the records prior to inpatient admission.

Based on interview, and record review, the hospital failed to ensure Patient 1's care plan was developed to reflect the patient's behaviors. Failure to develop a care plan resulted in the patient assaulting his roommate (Patient 2) and possibly putting all the patients, and hospital's staffing at risk for serious injury/harm.

Findings:

Review of the facility's policy and procedure (P&P) titled "Interdisciplinary Plan Care," reviewed on 3/2019, showed in part, the care plan should be started by the patient's primary nurse, or nurse who admits the patient.
The section for "Patient Problems and/or Care Needs," indicated the following:
-Problem identification is initiated by a Registered Nurse (RN) or qualified professional based on direct observation and evaluation of data gathered.
-The RN is responsible for analyzing, synthesizing and evaluating data and identifying appropriate nursing diagnoses/patient problems.
-Problems identification and development of Plan of Care individualized and ongoing process throughout a patient's hospitalization.

On 2/18/20, review of Patient 1's medical records was initiated.

Review of Registered Nurse (RN 1-primary nurse) Progress Note Non-Physician dated 1/31/20, showed the following:

At 8:23 AM, Patient 1 stated, "Nurse, nurse, I heard the guy next to me yell "Reggie, Reggie!" RN at bedside, did not hear patient in next bed yell out patient's name. Patient appeared to have paranoid thoughts. Comforted patient that he is in a safe place and that he is being monitored. Will keep monitoring patient's behavior. Suggested sitter for patient to Charge Registered Nurse.

At 9:24 AM, phlebotomists attempted to draw patient's blood at bedside, patient cooperated. However, changed his mind and refused. Patient stated "get out of my room."

At 10:15 AM, RN found patient resting in bed with his eyes closed, but easily arousable. Patient 1 stated "He (Patient 2) was trying to rape me." Patient 1 was reoriented he is in a safe place, and that he is at hospital. Patient 1 did not exhibit any threatening behavior at this time. Will keep monitoring.

At 10:45 AM, showed in part, "tried to get history from patient, unable to recall past medical history but admits to meth (crystal methamphetamine, a strong and highly addictive drug that affects the central nervous system) use yesterday."

At 11:22 AM, was informed Patient 1 had punched Patient 2. Patient 2 was found unconscious and snoring. Patient 1 was removed from the room and temporarily moved to another room with a sitter at bedside.

At 11:30 AM, upon arrival to room with sitter, Patient 1 admitted he punched Patient 2 because "He was trying to crawl in bed with me and trying to rape me." Patient 2 stated he had punched the patient "many times" with his left hand. Sitter at bedside and will continue to monitor patient.

Although RN 1, (primary care nurse) on duty identified Patient 1 had used substance abuse the day before, and was having paranoid thinking (defined as persecutory, or beliefs of conspiracy concerning a perceived threat) towards Patient 2, and needed monitoring, she did not develop a care plan with interventions, including a method of monitoring or supervision, specific frequency, and level of supervision, to ensure other patients were not subjected to Patient 1 possible physical assault.

During an interview with RN 1 on 2/18/20, at 12 PM, she confirmed she did not develop a care plan to address monitoring/level of supervision.

During an interview with the Chief Nursing Officer (CNO) on 2/19/20, at 12:30 PM, she confirmed there was no care plan developed to address Patient 1's supervision. She stated there were two staff members available to initiate closed supervision (one to one sitters are responsible for continuous observation in order to prevent injuries to high-risk patients).