HospitalInspections.org

Based on document review, the facility failed to provide care in a safe setting for 1 of 10 patients. (P1)

Findings include:

1. The facility policy titled," Patient Rights and Responsibilities", PolicyStat ID 10789501, last revised 5/2022, indicated as a patient of H1, you have the right to be free from mental, physical, sexual and verbal abuse, neglect or harassment and/or exploitation.

2. Significant Event documentation dated 10/2/23 at 7:25 pm indicated nursing staff were watching P2 during 2:1 observation in the common area. P1 was confused and repeatedly came to the table where the two nursing staff members and P2 were playing a game. Nursing staff asked the patient multiple times to remove him/herself from the area d/t safety concern. The patient would be reluctant to remove him/herself from the situation but would eventually leave the area. P1 would come up to the table , stare, and try to take off his/her gown. Nursing staff helped the patient put the gown back on multiple times. Afterwards, P1 was walking by the table again, when P2 turned and charged P1. P2 put P1 in a headlock but did not quite get his/her arm around P1's neck. Nursing staff grabbed and broke P2's grip around P1, P1 was removed from the situation safely. P1 was taken to his/her room and checked for injury. No redness or bruising was noted on his/her neck, pt claimed, "I am not hurt". P1 was provided emotional support and distraction after the event.

3. The medical record for P1 lacked interventions to keep the patient away from P2 or closer observation of P1 to ensure safety.