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Based on observation, interview, and record review, the hospital failed to protect and promote patient's rights to care in a safe setting for 3 of 10 patients reviewed (P, P2) when P2 attacked P1 physically resulting in a concussion, and P5 when P5 swallowed a foreign object requiring medical intervention for removal.

Findings include:

The hospital did not meet the Condition of Patient Rights at 42 CFR 482.13. This deficient practice had the potential to impact all patients at the hospital.

An immediate jeopardy (IJ) was called on 4/22/19, at 4:40 p.m. The hospital director of nursing and chief nursing officer were notified of the IJ at that time. The IJ began on 4/14/19, at at 3:08 p.m. when hospital staff failed to adequately supervise violent patients, and P14 physically attacked P13 in the day room when no staff were present to supervise patients. P14 was able to punch P13 in the head over 40 times before staff intervened. The hospital's established protocols for supervision of patients were not implemented by staff. The failure to ensure staff followed the hospital's protocols related to patient supervision resulted in the hospitals inability to protect patient health and safety, therefore the hospital was unable to meet the Condition of Participation of Patient Rights

The IJ was removed on 4/23/19, at 4:30 p.m. when an acceptable IJ removal plan was verified as implemented to ensure the health and safety of patients. Observation, interview, and document review verified that hospital leadership had begun a process of reeducating staff regarding supervision of violent patients.

The hospital remained out of compliance with the Condition of Patient Rights at 42 CFR 482.13. The following condition level deficiency is issued. See A144.

Based on observation, interview, and record review, the hospital failed to protect and promote patient's rights to care in a safe setting for 3 of 10 patients reviewed (P1, P2, P5) when hospital staff failed to provide adequate supervision. P2 attacked P1 physically, resulting in a concussion, and P5 swallowed a foreign object resulting in medical intervention in an acute hospital setting. Findings include:

P1 and P2:

P1's medical record review revealed P1 was admitted to the hospital on 12/14/18, with diagnoses that included schizoaffective disorder and a history of traumatic brain injury.

P1's Psychiatric Assessment dated 12/14/18, revealed P1 was civilly committed to the hospital. P1's history included a history of violence, including attempting to stab a previous physician, and P1 was awaiting a hearing related to a commitment status as mentally ill and dangerous. P1's treatment plan included frequent observations due to violence toward others.

P1's Violence Risk Assessment dated 4/4/19, revealed P1 was assessed by hospital staff as having a high risk of violent behavior.

A review of P1's hospital record from a local acute care hospital (Hospital X) dated 4/14/19, revealed P1 was seen in the emergency room as a result of injuries sustained in an assault by another patient. P1 had atrial fibrillation and was on the blood thinner Eliquis. P1 was hit in the head multiple times by a peer. P1's diagnoses after discharge from Hospital X included closed head injury and contusion of the right wrist.

P2's medical record review revealed P2 was admitted to the hospital on 8/9/17, with diagnoses that included schizophrenia and polysubstance abuse disorder. P2 was civilly committed to the hospital.

P2's Psychiatric Assessment dated 8/7/18, revealed P2's history included commitment as a level 3 sex offender, and physical violence. P2's treatment plan included routine observations.

P2's Violence Risk Assessment dated 9/2/18, revealed P2 was assessed by hospital staff as being at low risk for violence.

On 4/22/19, at 2:30 p.m. hospital video was observed with the hospital director of nursing (DON)-B. Observation of video dated 4/14/19, at 3:11 p.m. revealed P1 was sitting in the day room with four peers and no staff in the room. P2 entered the day room, ran after P1, tackled him to the ground and began punching P1 in the head. P2 delivered over 40 blows to P1's head and torso before hospital staff noted the altercation from outside of the day room, and intervened to restrain P2 and stop the assault. When DON-B was queried about the video, she confirmed that there were no staff in the day room, and hospital practice is that staff should always be in the day room when patients are in there in order to provide patient supervision. DON-B stated she was shocked no staff were in the day room with patients that day.

During an interview on 4/22/19, at 1:45 p.m. registered nurse (RN)-J stated she worked the evening shift on 4/14/19. She was not in the day room, so she did not witness the initial incident, but she heard in report that P1 was antagonizing P2 on the day shift and P2 was upset. Staff were told to keep an eye on them on the evening shift.

During an interview on 4/22/19, at 2:00 p.m. RN-K stated report was starting on 4/14/19, and he suddenly heard "Fight, fight" and he ran to the day room. He saw P2 on top of P1 hitting P1. He pulled P2 off of P1. RN-K stated P1 is very intrusive with his behavior consistently.

During an interview on 4/22/19, at 2:05 p.m. RN-L stated she worked days on 4/14/19. She stated P1 had threatened P2 on the day shift. RN-L stated she called Physician A to report the concern, who gave an order to give P2 his evening medications early. RN-L stated she gave P2 his medications at about 3:00 p.m. RN-L stated she was not in the day room when the assault happened, but heard a code being called for P1 and P2.

During an interview on 4/22/19, at 2:15 p.m. licensed practical nurse (LPN)-M stated she was working when the assault occurred. She stated earlier in the day, P1 and P2 were talking and P2 stated, "I don't fight, I kill." The two patient's were separated. About 10 minutes later, P2 asked if he would be moved if he got into a fight. LPN-M was not in the day room when the assault occurred. The next thing she knew, she heard commotion from the day room and P2 had assaulted P1.

During an interview on 4/22/19 at 3:05 p.m. DON-B and chief nursing officer (CNO)-H stated that the hospital had no policy related to staff providing supervision in the day room when patients are in the room, but it has always been hospital practice to ensure there were staff in the day room for supervision when patients are in the room.

P5:

P5's medical record review revealed P5 was admitted to the hospital on 2/26/19, with diagnoses that included schizoaffective disorder, neurocognitive disorder, and substance use disorder. P17 was pregnant at the time of admission, and gave birth on 4/5/19.

P5's Psychiatric Assessment dated 2/26/19, revealed P5 had a history of impulsive ingestion of foreign objects. P5's treatment plan on admission included 2:1 staffing for supervision related to her swallowing behavior and aggression. P5's treatment plan dated 4/11/19, revealed P5's supervision had been modified to 1:1 staffing for safety.

P5's medical record from Hospital X dated 4/18/19, revealed P5 was seen in the emergency room related to ingestion of a foreign object. A CT dated 4/18/19, revealed an ingested foreign body consistent with a folded underwire from a bra was located in the esophagus. P5 underwent EGD for removal of the foreign body, and then returned to the sending hospital.

An incident report dated 4/18/19, revealed P5 was in the shower and the staff member assigned the 1:1 supervision for P5 was in the room. P5 handed the staff member her bra and told the staff member that she had just swallowed the underwire from the bra. P5 was sent by ambulance to Hospital X.

The hospital critical Incident review (CIR) undated, was reviewed and revealed the staff member with P5 on 4/18/19, while she was in the shower, was standing outside the curtain while P5 was showering, not able to visualize P5.

During an interview on 4/23/19, at 1:15 p.m. RN-D stated the hospital identified that the staff member conducting the 1:1 with P5 on 4/18/19, did not follow hospital 1:1 policy to keep P5 in sight at all times while completing the 1:1 staffing for patient supervision.

The policy titled Therapeutic Observations, dated 4/2/19, directed under the section Definitions: Close 1:1 Observation: Staff assigned must observe the client in close proximity with immediate physical access and no physical barriers between staff and client, and maintain continuous visual observation.