HospitalInspections.org

Based on hospital policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients received care in a safe setting for 15 of 16 (Patient #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and Random Patient #1) sampled patients.

The facility's failure to ensure all patients received care in a safe setting placed all 15 patients observed on the unit with Patient #1 in an IMMEDIATE threat for their health and safety.

The findings included:

1. Review of the hospital policy titled, "Scope of Service/Provision of Patient Care" revised 3/2024 revealed, "...the goal of the hospital is to provide safe and supportive environments for patients, staff and visitors...The primary goal of nursing services is to provide planned, comprehensive, therapeutic, safe, and consistent nursing care...".

Review of the hospital policy titled, "Patient Rights, ADM 01-15" revised on 2/2020 revealed, "...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...".

Review of the hospital policy titled, "Observations, Patient" revised 7/2021 revealed, "...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [Registered Nurse]...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Patient is placed on Q [every] 5 minutes if their behaviors is unpredictable and there is potential risk for harm to self and others yet behaviors is not at the point requiring constant 1:1 observation...Patient is monitored at minimum once in every 5-minute block of time...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...".

2. Review of the hospital document titled, "Chief Nursing Officer Job Description" dated 1/1/2020 revealed, "...Recognize that patient safety is a top priority...".

Review of the hospital document titled, "RN Job Description" dated 1/1/2020 revealed, "...Recognize that patient safety is a top priority...".

Review of the hospital document titled, "Behavioral Health Associate [Behavioral Health Technician (BHT)] Job Description" dated 1/1/2020 revealed, "...Recognize that patient safety if a top priority...Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precaution, or in accordance with individualized supervision guidelines as needed...Document timely, accurate and appropriate clinical information in patient's medical record...Assist in providing a safe, secure and comfortable environment for patients, significant other and staff...Interact routinely with patients, observe behaviors and communicate significant observations to nursing staff...".

Review of the hospital documents titled, "Immediately-For Your Safety, Please Follow This Process" revealed, "I attest that I understand that I am responsible for escalating situations that could lead to a significant patient or staff incident...Patient making verbal threats of physical harm, unresolved by unit staff...Patients escalating or high acuity on the unit, unresolved or uncontrolled by unit staff." The documents were signed by BHT #2 on 3/21/2024 and by BHT #1 on 3/22/2024.

Review of the hospital's incident log revealed Patient #2 was "Injured by Other Patient" on 5/25/2024 at 7:55 PM.

Review of a facility incident reported to the Survey Agency on 5/31/2024 revealed, "...On May 25, 2024...At 1955 [7:55 PM] [Patient #2 was attacked by Patient #1] unprovoked in the hallway, the attack lasted less than 30 seconds but caused significant injuries to [Patient #2]...Investigation initiated...".

3. Medical record review for Patient #1 revealed a 34 year-old male admitted on 4/24/2024 with diagnoses which included Schizoaffective Disorder, Bipolar Type. (Schizoaffective Disorder, Bipolar Type is a mental illness characterized by symptoms such as hallucinations - seeing and/or hearing things that aren't there, and delusions (having false or unrealistic beliefs or opinions), and symptoms of a mood disorder such as depression, mania or hypomania (periods of great excitement or euphoria, delusions, and overactivity).

Review of the physician's orders dated 5/24/2024 at 7:24 PM revealed Patient #1 was to be admitted to the hospital's General Psychiatric Unit with Suicide Precautions and Assault Precautions and should be observed by staff every 5 minutes.

Review of a Nurse Progress Note written by Registered Nurse (RN ) #1 on 5/25/2024 at 11:54 PM revealed, "[Patient #1] severely beat another patient. The fight was broken up and [Patient #1] was placed in seclusion...has no injuries or complaints of pain. [Patient #1] will be discharged and taken by [Local police department]...".

Review of a Progress Quick Note written by the Medical Director on 5/26/2024 at 3:47 PM revealed "...I was notified last night per HS [House Supervisor] pt [Patient #1] assaulted another pt [Patient #2] on the unit and left the hospital in the custody of [Local police department]...".

4. Medical record review for Patient #2 revealed a 45 year-old male admitted on 5/24/2024 with diagnoses which included Major Depressive Disorder, Recurrent, Severe with Psychotic Features.

Review of the physician's orders dated 5/24/2024 at 10:04 AM revealed Patient #2 was to be admitted to the hospital's Dual Diagnosis Unit (DDU). The order was changed at 10:06 AM to admit to the hospital's General Psychiatric Unit (GPU). Further review revealed Patient #2 should be placed on assault and suicide precautions and should be observed by staff every 5 minutes.

Review of a Nurse Progress Note written by RN #1 dated 5/26/2024 at 9:43 PM revealed Patient #2 was observed on the floor with Patient #1 on top of him. Patient #1 was hitting/striking Patient #2's head. Staff intervened and pulled Patient #1 off of Patient #2. After being pulled off of Patient #2, Patient #1 was able to kick Patient #2 in the head 3 times before the incident ended. Patient #2 was unresponsive and was showing signs of damage to his brain. Staff called emergency medical services (EMS) and police. Patient #1 was taken into police custody, and Patient #2 was transported to Hospital #2 for further care.

5. Review of the Behavioral Health - Patient Observation Sheets for both Patient #1 and Patient #2 revealed BHT #2 documented both patients were asleep in their rooms during the time the incident occurred. Further review revealed both patients had orders to be observed by staff every 5 minutes; however, those observations were not completed per physician's orders.

6. Review of the hospital's video recording of the North hallway, dayroom, and South hallway dated 5/25/2024 from 7:49:58 PM until 8:00:51 PM revealed the cameras did not capture the incident due to the use of portable air conditioning units that were in use which obstructed the South hallway from camera view. The video recording did show both Patient #1 and #2 prior to the incident, then Patient #1 was back in view in the dayroom unsecured with a total of 14 other patients. The video recording stopped before any police or ambulance personnel arrived on scene.

7. Interviews were conducted with personnel who witnessed and/or responded to the incident. Two employees refused to be interviewed. Their written witness statements were reviewed.

8. Patient #3, #4,#5,#6, #7, #8, #9, #10, #11, #12, #13, #14, and #15's medical records were reviewed and revealed all 13 of the patients viewed on the hospital's video recording, were documented as being asleep in their rooms at the time of the incident although video recording showed them in the day room.

Refer to A144.

Based on hospital policy review, document review, medical record review, video recording review, and interview, the hospital failed to ensure all patients received care in a safe setting for 15 of 16 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) sampled patients and 1 of 1 (Random Patient (RP #17) random patients reviewed.

The findings included:

1. Review of the hospital policy titled, "Scope of Service/Provision of Patient Care" revised 3/2024 revealed, "...Care is provided according to an established code of ethical conduct and strict adherence to patient rights...From a facilities perspective, the goal of the hospital is to provide safe and supportive environments for patients, staff and visitors...Adult Services...Patients are admitted to one of the units based on clinical criteria...For the male population who are severely acute, demonstrating psychotic features and at risk for behavioral issues, a physician will provide an order to the patient will be admitted to GPU (General Psychiatric Unit)...Nursing Services...The primary goal of nursing services is to provide planned, comprehensive, therapeutic, safe, and consistent nursing care...Additional responsibilities of nursing staff include...providing opportunities for leaning about self and exploring patterns of interaction within a safe environment...".

Review of the hospital policy titled, "Patient Rights, ADM 01-15" revised on 2/2020 revealed, "...All personnel are responsible for adherence to the principles as outlined in the "Patient Rights."...The patient has the right to considerate, respectful care at all times and under all circumstances...Be placed in protective privacy when considered necessary for personal safety...Personal Safety 1. The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...".

Review of the hospital policy titled, "Observations, Patient" revised 7/2021 revealed, "...In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN [Registered Nurse]. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level...The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change: a. 15 minute b. 5 minute c. One-to-one 2. The psychiatric practitioner may also order a precaution level of observation for: a. Suicide b. Assault...f Sexual Acting Out 3. The RN may increase the level of observation if the patient's condition changes...4. The RN may not decrease the level of observation...without an order by the psychiatric practitioner...Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following...Level of observation...Precaution...Location...Behavior...Activity...Time...Staff Initial and Signature...Documentation of the observation is to be completed once the patient has been observed...All patients are monitored at minimum once in every 15-minute block of time...During the rounds staff are to...Make direct visual contact; look for signs of danger or distress...Remain vigilant for specific risks for patients on Special Precautions...Q 5 Minute Rounds a. Patient is placed on Q 5 minutes if their behaviors is unpredictable and there is potential risk for harm to self and others yet behaviors is not at the point requiring constant 1:1 observation...Patient is monitored at minimum once in every 5-minute block of time...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...".

2. Review of the hospital document titled, "Chief Nursing Officer Job Description" dated 1/1/2020 revealed, "...Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective and efficient use of operation of nursing, other departments and the delivery of behavioral health/nursing services with a positive, empathetic, and professional attitude toward customers. Recognize that patient safety is a top priority...Demonstrates a sense of urgency related to the importance of patient safety...Oversee nursing services documentation to ensure it meets all standards...".

Review of the hospital document titled, "RN Job Description" dated 1/1/2020 revealed, "...Purpose Statement: Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority.

Review of the hospital document titled, "Behavioral Health Associate [Behavioral Health Technician (BHT)] Job Description" dated 1/1/2020 revealed, "...Purpose Statement: Responsible for providing personal care services to patients at the facility under the direction of the clinical or nursing leadership...Recognize that patient safety if a top priority...Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precaution, or in accordance with individualized supervision guidelines as needed...Document timely, accurate and appropriate clinical information in patient's medical record...Assist in providing a safe, secure and comfortable environment for patients, significant other and staff...Interact routinely with patients, observe behaviors and communicate significant observations to nursing staff...".

Review of the hospital documents titled, "Immediately-For Your Safety, Please Follow This Process" revealed, "I attest that I understand that I am responsible for escalating situations that could lead to a significant patient or staff incident. I understand that failure to follow the chain of command will result in disciplinary action. Examples of incident that could result in the use of this chain of command...Patient continuously antagonizing you or a peer, unresolved by unit staff...Patient making verbal threats of physical harm, unresolved by unit staff...Patients escalating or high acuity on the unit, unresolved or uncontrolled by unit staff." The documents were signed by BHT #2 on 3/21/2024 and by BHT #1 on 3/22/2024.

Review of the hospital's incident log revealed Patient #2 was "Injured by Other Patient" on 5/25/2024 at 7:55 PM. The incident log further revealed Patient #1 was placed in "Seclusion" on 5/25/2024 at 8:00 PM.

Review of a facility incident reported to the Survey Agency on 5/31/2024 revealed, "...On May 24, 2024 [Patient #2 and Patient #1] both admitted to [Hospital #1] on GPU...The history and physical for [Patient #2] acknowledges a previous gunshot wound to the head in 1994, no significant indication on the History and Physical of [Patient #1]. On May 25, 2024, up until the time of the incident, [Patient #1 and Patient #2] were both reported and documented as being calm, cooperative and as having no issues, either individually or with each other. At 1955 [7:55 PM] [Patient #2 was attacked by [Patient #1] unprovoked in the hallway, the attack lasted less than 30 seconds but caused significant injuries to [Patient #2]...Investigation initiated...".

3. Medical record review for Patient #1 revealed a 34 year-old male admitted on 4/24/2024 with diagnoses which included Schizoaffective Disorder, Bipolar Type. (Schizoaffective Disorder, Bipolar Type is a mental illness characterized by symptoms such as hallucinations - seeing and/or hearing things that aren't there, and delusions (having false or unrealistic beliefs or opinions), and symptoms of a mood disorder such as depression, mania or hypomania (periods of great excitement or euphoria, delusions, and overactivity).

Review of the hospital's Emergency Medical Treatment and Labor Act Medical Screening Examination (MSE) dated 5/24/2024 at 12:20 PM revealed Patient #1 had a past medical history of Hypertension (High blood pressure). The MSE further revealed the patient was exhibiting both suicidal ideations (SI) and homicidal ideations (HI) and had symptoms of extreme psychosis including auditory hallucinations to harm himself. The patient was deemed medically stable for further psychiatric evaluation.

Review of the Crisis Assessment dated 5/24/2024 at 2:28 PM revealed Patient #1 presented to the assessment center on his own. The assessment further revealed, "PT [patient - Patient #1] is reporting suicidal ideation with plan and intent and access to means to starve himself...due to no access to food ..., or way to get around...PT is homicidal with plan to light unknown gas station on fire per pt due to "mistreating him" per pt. Pt is psychotic hearing AH [ auditory hallucinations] psychosis of the animals talking to him and asking him for wishers per pt. PT denying substance use...PT is depressed and anxious ongoing asking for PRN [as needed] anxiety...PT cannot safety plan and needs stabilization...".

Review of the Intake Assessment dated 5/24/2024 at 6:15 PM revealed, Patient #1 was "...experiencing SI [suicidal ideation] w [with] plan to walk into traffic ... with intent to blowup gas station...Hearing command voices to kill self and blow up gas station with people inside. Off meds [medications] for several days...Observed to be restless and fidgety...Distracted Flight of Ideas Limited Attention Span hallucinations...Legal Admission Status Voluntary...Diagnosis per Physician...Schizoaffective D/O [disorder], Bipolar Type...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...".

Review of the physician's orders dated 5/24/2024 at 7:24 PM revealed the patient was to be admitted to the hospital's General Psychiatric Unit with Suicide Precautions and Assault Precautions and should be observed by staff every 5 minutes.

Review of the nursing Admit Assessment dated 5/25/2024 at 12:57 AM revealed Patient #1 reported, "I've been hearing voices telling me to walk into traffic & [and] kill myself, & to blow up a gas station with people in in [it]... Psychiatric Assessment...calm, cooperative, anxious & restless sitting in chair, then standing waiting for nurse; flat affect, depressed mood, no eye contact...Aggression None...".

Review of the Patient #1's Psychiatric Evaluation completed by Psychiatrist #1 on 5/25/2024 at 8:30 AM revealed, "...history of schizoaffective disorder, bipolar type and cocaine use disorder mild. Pt [patient] presents with SI with plan to walk into traffic. Reports HI [homicidal ideation] with plan to blow up a gas station. Hearing voices urging him to kill self and others in this manner. Speech is pressured, rambling with racing thoughts with illogical and disorganized thought process. paranoid and watchful of others. Sexually inappropriate speech at times...Has difficulty concentrating and following conversation. he has a history of using amphetamines, methamphetamine, cocaine...Psychomotor Behavior Agitation, Hyperactivity Attitude - Behavior Guarded, irritable...Affect irritable...Risk Factors Suicidal Ideation, Homicidal Ideation...Justification for Hospitalization - Inpatient Failure of treatment at a lower level of care, Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning, Dangerous to self, others or property with need for controlled environment..."

Review of the Patient #1's History and Physical completed by the Medical Director on 5/25/2024 at 12:19 PM revealed, "...recently discharged from the hospital, history of schizoaffective disorder, bipolar type, drug abuse, readmitted to the hospital with suicidal ideation with plan to walk into traffic. Reports homicidal ideation with plan to blow up gas station, paranoid and watchful of others, sexually inappropriate speech, at times displaying severe thought blocking. He has trauma history of being sexually abused by a sister at age 3, his mother passing in 2018, and father dying in 2021. Poor sleep and appetite. Readmitted to the hospital with a diagnosis of schizoaffective disorder. He has had many prior psychiatric hospitalizations..."

Review of a Nurse Progress Note written by Registered Nurse (RN ) #1 on 5/25/2024 at 11:54 PM revealed, "[Patient #1] severely beat another patient [Patient #2]. The fight was broken up and [Patient #1] was placed in seclusion...[Patient #1] has no injuries or complaints of pain. [Patient #1] will be discharged and taken by [Local police department]..."

Review of the Behavioral Health - Patient Observation Sheet dated 5/25/2024 revealed for Patient #1 revealed the following:
At 7:22 PM - BHT #1 documented Patient #1 was observed in the dayroom exhibiting appropriate behaviors.
At 7:37 PM, a total of 14 minutes later, BHT #2 documented Patient #1 was observed in his room and appeared to be asleep.
At 7:51 PM, a total of 14 minutes later, BHT #2 again documented Patient #1 appeared to be asleep in his room. At 7:59 PM, a total of 7 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room.
At 8:29 PM, a total of 30 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room.
Further review of the Observation Sheet revealed Patient #1 was exhibiting appropriate behaviors and was moved to the Seclusion Room by BHT #3 at 9:06 PM.
At 9:23 PM, a total of 14 minutes later, BHT #3 documented Patient #1 was observed in the seclusion room exhibiting appropriate behavior.
At 9:34 PM, a total of 11 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room.
Patient #1 was observed by BHT #4 in the seclusion room from 9:43 PM until 11:41 PM.
At 11:51 PM, 10 minutes later, BHT #2 documented Patient #1 appeared to be asleep in his room.

Facility staff failed to observe and document Patient #1's location and behaviors every 5 minutes as ordered.

BHT #2 failed to accurately document Patient #1's location and behaviors on 5/25/2025 when she documented the patient appeared to be asleep in his room at 7:51 PM and 7:59 PM, as the patient was observed by this surveyor on video walking up and down the hallway and pacing in the dayroom. BHT #2 also failed to accurately document Patient #1's location at 9:34 PM and 11:51 PM when the patient was actually in the seclusion room, not in his room.

Review of a Progress Quick Note written by the Medical Director on 5/26/2024 at 3:47 PM revealed "...I was notified last night per HS [House Supervisor] pt [Patient #1] assaulted another pt [Patient #2] on the unit and left the hospital in the custody of [Local police department]...".

4. Medical record review for Patient #2 revealed a 45 year-old male admitted on 5/24/2024 with diagnoses which included Major Depressive Disorder, Recurrent, Severe with Psychotic Features.

Review of the Intake Assessment dated 5/24/2024 at 8:00 AM revealed Patient #2 presented to the hospital with "rambling speech and suicidal ideations w/a [with a] plan to cut his throat w/a knife...PT is endorsing depression due to minimal interaction w/ [with] family. PT is non-compliant w/ all prescribed psychotropic meds...Alcohol and Drug Use History...Cocaine...1 gram As money permits...Last Uses...Unknown...Easily agitated...Posture: tense/rigid...Mood: Anxious Manic...Motor Behavior: Restless...".

Review of the MSE dated 5/24/2024 at 8:15 AM revealed Patient #2 had a past medical history of Hypertension and arthritis. The MSE further revealed the patient was exhibiting SI with a plan of cutting his wrist, HI without any specific plan and was having auditory hallucinations with commands to hurt himself. Patient #2 was noted to be at risk of imminent harm to self/others due to psychiatric conditions...Acute psychiatric condition requires 24 hour skilled nursing/medical oversight Potential danger to self or others...".

Review of the Psychiatric Evaluation for Patient #2 completed by Psychiatrist #1 on 5/24/2024 at 9:46 AM revealed, "...admitted for depression and psychosis. Pt discharged in April. Reported SI no plan and is hearing voices to harm self. H/o [history of] at least two previous attempts. States he has been wandering the neighborhood and not realizing how he got there. H/o [history of] cocaine use but denies since dc [discharge] in April. Off meds...Unable to function...Attitude - Behavior Guarded, Irritable, Withdrawn Mood Depressed, Anxious, Irritable...Justification for Hospitalization - Inpatient...Hallucinations, delusions, agitation, anxiety, depression resulting in a significant loss of functioning. Dangerous to self, others or property with need for controlled environment...".

Review of the physician orders dated 5/24/2024 at 10:04 AM revealed Patient #2 was to be admitted to the hospital's Dual Diagnosis Unit (DDU). The order was changed at 10:06 to admit to the hospital's General Psychiatric Unit (GPU). Further review revealed Patient #2 should be placed on assault and suicide precautions and should be observed by staff every 5 minutes.

Review of the nursing Admit Assessment dated 5/24/2024 at 11:54 AM revealed Patient #2 reported, "I need to get back on my meds. I was thinking about suicide... Pt admitted to having a suicidal plan to either drive car off road or to cut wrists...Psychiatric Assessment..."[Patient #2] is irritable. Depressed with sad affect. Reports AH with commands that tell pt to harm himself...".

Review of the History and Physical for Patient #2 completed by the Medical Director on 5/24/2024 at 12:35 PM revealed, "...admitted for depression psychosis...suicidal ideation...Off medication, poor sleep...Unable to function. Diagnosis of admission is major depressive disorder...Past Medical History...noncompliance, history of smoking, drinking, using drugs, chronic pain, arthritis, renal insufficiency...".

Review of the Behavioral Health - Patient Observation Sheet for Patient #2 revealed staff documented Patient #2 was observed by staff every 5 minutes as ordered from the time of his admission on 5/24/2024 until 7:15 AM on 5/25/2024.
On 5/25/2024 at 7:15 AM, staff documented they observed Patient #2 every 15 minutes from 7:15 AM until 8:00 PM on 5/25/2024. Staff documented Patient #2 was in his room asleep on 5/25/2024 at 7:30 PM, 7:45 PM and 8:00 PM. There were no physician's orders to indicate Patient #2's observation frequencies were changed from every 5 minutes to every 15 minutes.

Observations of the hospital's video recording revealed Patient #2 was in the dayroom on 5/25/2024 at 7:49:58 PM until 7:52:22 PM when the patient walked across the dayroom and exited camera view into the South hallway. Eyewitness testimonies revealed Patient #2 was assaulted in the South hallway at approximately 7:55 PM and he remained in the hallway until local police and EMS personnel arrived around 8:06 PM and 8:11 PM.

The observations documented by BHT #2 on 5/25/2024 at 7:45 PM and 8:00 PM failed to accurately describe the Patient #2's location and behaviors.

Review of a Nurse Progress Note written by RN #1 dated 5/25/2024 at 9:43 PM revealed, "...this nurse saw [Patient #2] on the floor with [Patient #1] on top of him hitting him [Patient #2] in the head. The tech pulled [Patient #1] off of [Patient #2], but [Patient #1] ran up and stomped [Patient #2] in the head three times. [Patient #1] was removed from all of the patients and placed in seclusion. This nurse called for help and assessed the patient. EMS [emergency medical services] was immediately dispatched. patient [Patient #2] was unresponsive, with agonal and sonorous breathing, decorticate posturing, and had an obvious bloody/severe facial deformity as well as an obvious shoulder injury. [Agonal, sonorous breathing is insufficient breathing that often sounds like snoring, snorting, gasping, or labored breathing. Decorticate posturing is abnormal flexion of the arms with the extension of the legs. This pose may occur automatically because of damage to or disruptions in the brain.] Patient had a palpable pulse present and vital signs were obtained...[Patient #2] was transported off the unit with [local fire department] ALS [advanced lifesaving] unit via EMS to [Hospital #2] for a higher level of care at 2042 [8:42 PM]..."

Review of the Patient #2's Discharge Summary dated 5/25/2024 revealed Patient #2 was "...Pt was attacked by a male peer [Patient #1] while on unit. pt was transferred to [Hospital #2] for emergency care...Physical-Medical Condition on Discharge Unstable..."

5. Review of the "Incident Report" obtained from the local police department dated 5/25/2024 revealed Patient #1 was arrested for "Aggravated Assault" against Patient #2. The officers arrived at Hospital #1 at 8:06 PM in response to a "Fight call." The report revealed, "...Officers arrived on the scene and made contact with complainant [House Supervisor (HS)]...advised that they had a patient [Patient #2] on the third floor who was unresponsive. Officers arrived on the third floor and observed a male black subject in front of room #323 on the floor The subject appeared to have a dislocated jaw, laceration above his head, and a bloody mouth. Officers then made contact with [BHT #2]...[BHT #2] advised that she witnessed the entire incident...advised that the victim/patient, [Patient #2] had a verbal altercation with [Patient #3], another patient at the facility. [BHT #2] advised that [Patient #3] made threats to harm [Patient #2]...[BHT #2] advised that [Patient #3] stated, "Imma knock you out." [Patient #3] then stated, "They messing with me."...[BHT #2] advised that [Patient #2 ignored [Patient #3]...[BHT #2] advised that a third patient [Patient #1]...walked from the front lobby towards [Patient#2] and struck him the face with his right closed fist...[Patient #1] repeatedly struck [Patient #2] in the face and caused [Patient #2] to fall on the ground. [BHT #2] advised that she called for help...[BHT #1] assisted with the incident. Officers made contact with [BHT #1] who advised that he had heard [BHT #2] call for help and observed [Patient #1] stomping on [Patient #2] head. [BHT #1] advised that [Patient #1] repeated the assault until he pushed him into another room and off of [Patient #2]. [BHT #2] directed the officers to room #317, where [Patient #1] was located. [Patient #1] appeared to be out of it and spaced out. Officers gave [Patient #1] commands, and [Patient #1] complied. [Patient #1] advised that he was blind and stared into the air. Officers placed [Patient #1] into the facility conclusions [seclusion] room. [EMS unit] made the scene and transported [Patient #2] to [Hospital #2] in critical condition...Officer spoke with [Psychiatrist#1], who is [Patient #1] doctor at the time. [Psychiatrist #1] advised that [Patient #1] would be discharged from the facility due to the fear of the other patient and staff safety..."

6. Review of the Prehospital Patient Record report obtained from EMS revealed the EMS unit was dispatched to the hospital for an assault on 5/25/20254 at 8:01 PM. The unit arrived at the hospital at 8:09 PM, was with Patient #2 at 8:11 PM and left the hospital with Patient #2 at 8:30 PM in route to Hospital #2. The report revealed, "...45 y/o male [Patient #2] lying unresponsive in the hallway after being assaulted by another pt [Patient #1]. The nurses on scene stated the pt's [Patient #2] head was stomped on several times very hard before they could break up the fight. The pt [Patient #2] did lose consciousness before opening his eyes a few moments later...The pt [Pateint #2] was responsive to pain only and had decorticate posturing. pt [Patient #2] was breathing rapidly with blood in his airway. Pt [Patient #2] had massive facial trauma with swelling and deformity all over his face and he had several teeth knocked out. No other obvious injuries were noted anywhere else on the pt. Pt's [Patient #2] pupils were equal and unresponsive to light, skin warm/diaphoretic, and BS [breath sounds] had bilateral stridor due to blood in the airway. Pt had a GCS [Glasco Coma Scale] of 9 [The Glasco coma scale is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. It is the summation of scores for eye, verbal and motor responses. The minimum score is 3 which indicates deep coma or a brain dead state. the maximum is 15 which indicates a fully awake patient.]...a c-collar [cervical spine collar] was placed on pt, vitals taken...pt's airway was suctioned multiple times due to bleeding, 3 lead EKG [electrocardiogram] performed (sinus tach[tachycardia]) [An EKG measures the electrical activity of the heart]. Sinus tach is an abnormally rapid heart rate usually in excess of 100 beats per minute.]...IV [intravenous catheter] was placed...a bolus of LR's [lactated ringers, an IV fluid solution] was hung wide open...transported to [Hospital #2] in critical condition...pt [Patient #2] was sent to shock trauma and care transferred..."

7. Review of Patient #2's History and Physical Report obtained from Hospital #2 dated 5/25/2024 at 9:08 PM revealed Patient #2 was as assault victim and his "...face stomped. On arrival to trauma bay, he was GCS 6...and hypertensive. He was also posturing on arrival. He began desatting [desaturating] to the 70s so he was bag masked and prepared for intubation. [Desatting refers to oxygen levels in the blood are dropping.] He was then intubated. [Intubation is a procedure used to place a tube in the patient's mouth or nose down through into the trachea (windpipe). The tube keeps the patient's airway open so air can get to the lungs.] OGT [NGT (nasogastric tube)] [A naso-gastric tube is a procedure in which a tube is inserted into the patient's nose down through the back of the throat, esophagus (food tube) and into the stomach.]...and foley [indwelling urinary catheter] placed He was taken to CT [computerized tomography] scanner...Physical Examination...Eyes: 4 mm [millimeters] and sluggish b/l [bilaterally] Face/Neck...peri-orbital edema [swelling] encompassing the right side of the face. blood in mouth and missing teeth...Neurologic & Psych [psychiatric] GCS 6...Posturing..." The patient had CT scans of the head, cervical spine, chest, abdomen, pelvis and maxillofacial areas as well as a CT angiogram of the brain and neck, and x-rays of the chest and pelvis. The report revealed "...Impression and Plan Assessment: Assault...Injuries: 6 mm R [right] SDH [Subdural Hematoma, trapped blood that develops between the inner layers and the tough outer covering of the brain called the dura] 8 mm L [left] SDH 5 mm parafalcine SDH [A parafalcine subdural hematoma is a rare subtype of intracranial hematoma, or brain hemorrhage that can occur in the brain or within the three layers that cover the brain.] 8 mm R frontal SDH b/l [bilateral] SAH [subarachnoid hemorrhage. A subarachnoid hemorrhage is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia mater surrounding the brain.] R zygomatic arch fx [fracture The zygomatic arch or cheekbone is the arch of bone that extends along the front or side of the head around to the maxilla (upper jawbone).] small L PTX [pneumothorax A pneumothorax is the presence of gas (often air) in the cavity between the lungs and underneath the chest wall]."

Review of a Patient #2's Palliative Care Progress Note obtained from Hospital #2 dated 6/3/2024 revealed, "...admitted with TBI [Traumatic Brain Injury] and various injuries after an assault...Pt is s/p [status post] tracheostomy. current level of consciousness is consistent with unresponsive wakefulness syndrome (UWS) [Unresponsive wakefulness syndrome, formerly known as vegetative state, is one of the most dramatic outcomes of acquired brain injury. Patients with UWS open their eyes spontaneously but demonstrate only reflexive behaviors; there are no signs of consciousness.]..."

8. Review of the hospital's video recording of the dayroom and North hallway was completed with the hospital's Chief Operating Officer (COO) on 6/6/2024 beginning at 12:17 PM.
The video started on 5/25/2024 at 7:49:58 PM . The video showed the entire dayroom, the entire North hallway, and the entrance to the South hallway where Patient #1's and #2's rooms were located. The South hallway itself, was not visible in the video. Patient #2 was sitting in a chair in front of the nurse's station wrapped in a blanket. Patient #4, #5, #6, #7, #8 and Random Patient (RP #17) are in the dayroom and Patient #9 is visible at the far end of the North hallway, and BHT #1 was in the dayroom.
At 7:50:21 PM, Patient #2 stood up, turned and faced the nurse's station and appears to be knocking on the window.
At 7:50:35 PM, BHT #1 exited the dayroom leaving Patients #4, #5, #6, #7, #8, #9, and RP #17 in view. Patient #2 is still standing at the window to the nurse's station.
At 7:50:45 PM, Patient #3 walked into the dayroom, across the dayroom, then back out of the dayroom into the South hallway and out of view of the camera. Patient #2 continues to stand at the nurse's station window.
At 7:51:09 PM, Patient #9 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still standing at the nurse's station window.
At 7:51:16 PM, Patient #3 re-entered the dayroom from the South hallway. BHT #2 is visible in the North hallway holding a tablet and entering patient rooms.
At 7:51:24, BHT #2 exited the North hallway and walked into the dayroom. Patient #2 is still standing at the nurse's station and Patient #3, #4, #5, #6, #7, #8, and RP #17 were still visible.
At 7:51:34, BHT #2 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still standing at the nurse's station window. Patient #3, #4, #5, #6,#7, #8, and RP #17 are still visible.
At 7:51:58 PM, Patient #3 exited the dayroom and entered the South hallway out of view of the camera. Patient #2 is still at the nurse's station window. Patient #4, #5,#6, #7, #8, and RP #17 are still visible.
At 7:52:00 PM, BHT #2 was visible at the entrance of the South hallway, Patient #6 exited view at the top of the video near the medication room. Patient #4, #5, #7 ,#8, and RP #17 are still visible.
At 7:52:05 PM, BHT #2 moved out of view of the camera into the South hallway.
At 7:52:22, Patient #2 walked out of the dayroom into the South hallway out of view of the camera.
At 7:52:29: PM, BHT #1 re-entered the dayroom where Patient #4, #5,#6, #7, #8, and RP #17 were still visible.
At 7:52:38, BHT #2 is back in view of the camera at the entrance to the South hallway.
At 7:52:51 PM, BHT #2 was out of view in the South hallway. .
At 7:53:02, BHT #1 exited the dayroom leaving 5 patients in view. Patient #4, #5, #6, #7, #8, and RP #17 were still visible.
At 7:53:21 PM, Patient # 10 followed by Patient #9 entered the dayroom from the South hallway.
At 7:53:22, BHT #1 re-entered the dayroom where Patient #4, #5, #7, #8, #9,#10, and RP #17 were still visible.
At 7:53:35 PM Patient #1 entered the dayroom dressed in an orange and white outfit similar to a basketball uniform. The patient is seen walking back and forth in a pacing motion. Patient #9 has started walking down the North hallway. All other patients are still present; however, Patient #4 is now standing near the entrance to the South hallway. BHT #1 is still in the dayroom.
At 7:54:12 PM, Patient #1 continues to pace and began swinging his arms back and forth. BHT #1 is visible across the room from Patient #1 and is talking to Patient #9. BHT #1 was facing away from Patient #1.
At 7:54:19 PM, Patient #7 exited the dayroom into the South hallway out of view of the camera. Patient #1, #4, #5, #6, #9, #10, and RP #17 are still in view.
At 7:54:33 PM, Patient #1 exited the dayroom out of view of the camera into the South hallway. Patient #4, #5, #6, #7, #9, #10, RP #17, BHT #1 and RN #1 were visible in the dayroom.
At 7:54:35 PM, Patient #4 was looking down the South hallway and jumped backwards away from the South hallway. Both BHT #1 and RN #1 were still in view. RN #1 is facing Patient #4 and BHT #1 has his back toward Patient #4.
At 7:54:36 PM, Patient #4 continues to move in a fleeing motion away from the South hallway further into the dayroom. BHT #1 and RN #1 were still in the dayroom along with Patient #5, #6, #9, #10, and RP #17.
At 7:54:37 PM, Patient #4 began pointing down the South hallway alerting RN #1 and BHT #1 who turned toward the South hallway.
At 7:54:38 PM, RN #1 and BHT #