HospitalInspections.org

This standard is not met as evidenced by:

Based on record reviews, cameras recordings, and interviews, it was determined that the facility failed to provide an environment that ensured Patient B protection from harm. Findings include:

Interviews:

Interview with Staff #1 on 12/03/2024. Patient I and Patient B were playing basketball with peers in the gym on 11/15/2024 at 9:50am . Patient I bumped into Patient B. Patient B pushed Patient I. Patient I then punched Patient B in the face. Staff separated Patient I and Patient B.

Interview with Staff #5 on 12/11/2024 at 4:27pm. Patient I and Patient B were playing basketball, and Patient B got angry because the other team was winning. They started cursing each other. Patient I jumped in front of Patient B and hit him. That's when Staff #5 intervened and deescalated the issue. She stated she verbally told them to stop and separated them at the same time. Staff #5 stated, "When they were cursing I was walking toward where they were. The other staff was coming to come help me while they were cursing. Patient I slid right around me and punched Patient B. We could see the other kid, Patient I, went to try to fight another kid. He was on every 5-minute observations including gym time. That's why I was close to Patient I because he was known to fight."

Record Review: Patient B's medical record contained a nursing reassessment form that indicated Patient B had a chipped tooth as a result of a physical altercation.

Camera recording:

Facility provided camera recording of the gym on 11/15/2024 at 9:50am revealed that boys, including Patient B, were playing basketball. Staff #5 was standing less than three feet away from the boys. Patient B made a shot at the basket and missed. Patient I, who had previously been close to Patient B, had run about ten feet away. Patient B started walking quickly toward another peer just to side of the basket. Staff #5 followed and reached out and held Patient B's shoulder keeping him from getting closer to the peer. At this same time, Patient I ran from his position about ten feet away. He ran through Staff #5 and Patient B and punched Patient B in the face as he did so. Afterward, Patient B is seen walking toward the middle of the court with his hand to his mouth.

Record Review: Patient B's medical record contained a nursing reassessment form that indicated Patient B had a chipped tooth as a result of a physical altercation.

Policy review:

According to the facility's Patient and Family Handbook, patients have the basic right "to be treated with respect and dignity in a place that is clean and where you are protected from harm." (Basic Rights page 3 of 4). The facility failed to ensure this right as Patient B suffered a chipped tooth as a result of a physical altercation with Patient I on 11/15/2024.

Based on staff interviews, review of camera recordings, review of facility policies, and medical record review, the facilty failed to provide an environment that ensured patients were safe from harm in 1 out of 10 sampled patients (Patient B). This resulted in Patient B Being hit in the face and suffered a chipped tooth.