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Based on interview and record review, the facility failed to ensure a safe care setting when a patient was physically harmed by another patient for one of 30 sampled patients (Patient 1).

This deficient practice resulted in Patient 2 physically striking Patient 1 on the side of his (Patient 1's) head.

Findings:

During an interview on 6/14/22, at 9:50 a.m., with nurse manager (NM), NM stated, keeping Patient 1 and Patient 2 in the same unit (adult unit I) on 4/25/22 after Patient 2 threw a towel at Patient 1 at 10:00 a.m. NM stated, on 4/25/22, Patient 2 struck Patient 1 on the side of his head at 6:45 p.m. (2nd incident with Patient 1 and Patient on the same day) was, "Appropriate at the time (to keep patient 1 and patient 2 on the same unit)." NM stated, nurses, doctors, case managers, therapists, and mental health workers discuss the occurrence of such incidents and determined the appropriate interventions.

During an interview with Licensed Vocational Nurse (LVN) on 6/14/22, at 10:25 a.m., LVN stated, her primary responsibilities were patient assessments and medication administration. LVN stated, she has been employed at the facility for two years and had witnessed incidents of patient-to-patient assault.

During a review of Patient 1's "Psychiatric Evaluation" (Psych Eval), dated 4/17/22, the "Psych Eval" indicated, Patient 1 was admitted to the facility on a, "72-hour hold (involuntary admission) secondary to criteria of danger to others." The intervention was to perform every 15 minutes safety check (patient observation).

During a review of Patient 1's "Daily Nursing Flowsheet" (Nursing Notes), dated 4/25/22, the "Nursing notes" indicated, "Will provide safe and therapeutic environment". The "Nursing Notes" indicated, "Pt (Patient 1) was hit on side of head by another pt (Patient 2), unprovoked while sitting in group room."

During a review of Patient 2's "Psychiatric Evaluation" (Psych Eval), dated 4/25/22, the "Psych Eval" indicated, Patient 2 was admitted "because of threats to harm himself and hearing voices secondary to heavy meth use". The "Psych Eval" indicated, "He (Patient 2) was uncooperative and selectively mute and did not want to talk to me today."

During a review of Patient 2's "Daily Nursing Flowsheet" (Nursing Notes), dated 4/25/22, the "Nursing Notes" indicated, "(Patient 2) Presents with blunted affect, irritable mood, and responding to auditory hallucinations. Pt walked up to nurses station and threw a towel at peer (Patient 1) unprovoked" at 10:00 a.m. The "Nursing Notes" indicated, "Pt states "He was talking about me, tell him to leave me alone." while no other patient was around." The "Nursing Notes" indicated, "Pt moved to different room, closer to nurses station for closer observation and to be separated from roommate that he threw towel at." The "Nursing Notes" indicated, Patient 2 "appears to be fixated on roommate (Patient 1) and low risk for danger to others". The "Nursing Notes" indicated, "Pt unprovoked, hit same peer mentioned above (Patient 1) in day room, witnessed by peers" at 6:45 p.m. The "Nursing Notes" indicated, "Pt states, "he won't leave me alone, the voices bug."

During a review of the facility's policy and procedure (P&P) titled, "High Risk Assessment Precautions," last revised on 2/2/22, the P&P indicated, "All patients are assessed for risks for suicide/self-harm, assault, fall, sleep apnea, respiratory/sedation risk, seizures, sexual aggression, sexual victimization, vulnerability, and elopement upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. Patients will also be re-assessed for risk whenever there is an abrupt change in their behavior or mental status."

During a review of the facility's policy and procedure (P&P) titled, "Patient Abuse or Neglect," last reviewed on 01/2021, the P&P indicated, "It is the policy of (facility) to protect the elderly (65 years or older) and dependent adults from financial exploitation, sexual abuse, physical abuse and/or neglect (including self-neglect). This may include, but is not limited to abandonment, isolation, treatment resulting in physical harm, mental harm or suffering, and deprivation by a care custodian of goods and services that are necessary to avoid such harm or suffering." The P&P indicated, "Dependent Adults are defined as persons between the ages of 18 - 64 who has physical or mental limitations which restrict his/her ability to carry out normal activities or to protect his/her rights including, but not limited to, persons who have physical or mental disabilities or whose physical or mental abilities have diminished because of age."

Based on interview and record review, the facility failed to:


1. The facility failed to ensure documentation of patient assessment and notification of a patient's family following physical altercation between patients for 1 of 30 sampled patients (Patient 14) in accordance with the facility's policy and procedure. (Refer to A - 395)

2. The facility failed to ensure that the treatment plan for 1 of 30 sampled patients (Patient 17) was updated in accordance with the facility's policy and procedure. (Refer to A - 396).

3. Adhere to its policies and procedures for two of 30 patients addressing reporting of a patient to patient altercation.(Refer to A - 398).

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the Condition of Participation for nursing services was met.

Based on interview and record review, the facility failed to ensure documentation of patient assessment and notification of a patient's family following physical altercation between patients for 1 of 30 sampled patients (Patient 14) in accordance with the facility's policy and procedure.

This deficient practice had the potential to result in patient harm.

Findings:

During an interview 6/14/22, at 10:55 a.m., with Staff Nurse 1 (SN1), SN1 stated that Patient 17 was involved in a physical altercation with patient 14. SN1 stated Patient 17 was documented to have multiple incidents of being physically aggressive with staff and other patients.

During a concurrent interview on 6/14/22, at 10:55 a.m., with Chief Nursing Officer (CNO), CNO stated that the nurse failed to document a description of the incident, assessment and the notification of patient 14's parents on patients 14's chart after a physical altercation with another patient on 6/11/22. CNO further stated that the Facility identifies this failure as a deficiency.

During a concurrent interview and record review on 6/14/22, at 11:00 a.m., with Staff Nurse 2 (SN2), Patient 17's "Emergency Communication Tool," dated 6/11/22, was reviewed. The Emergency Communication Tool indicated Patient 17 "attacked male patient (Patient 14), pulled him (Patient 14) by the hair to the floor. SN2 stated, the male patient being referred to in the statement who was attacked was identified to be patient 14. The Emergency Communication Tool indicated there is no documentation of a description of events or notification to the provider or parent/ guardian on patient' 14's chart. SN2 said that Nurse should document a description of the incident, assessment and notification of parents on all physical altercations involving their patient.

During a review of the facility's policy and procedure (P&P), titled "Reassessment of Patient," last reviewed on 02/2020, the P&P indicated, reassessment is conducted by a Registered Nurse following any physical altercations. Findings from reassessment activities will be documented in the medical record and reported to the physician. Legal guardians of minors and conserved adults will be notified as applicable.

Based on interview and record review, the facility failed to ensure that the treatment plan for 1 of 30 sampled patients (Patient 17) was updated in accordance with the facility's policy and procedure.

This deficient practice had the potential for an inappropriate treatment plan to be provided to Patient 17.

Findings:

During a concurrent interview and record review on 6/15/22, at 10:20 a.m., with Chief Nursing Officer (CNO), Patient 17's "Master Treatment Plan Update/ Clinical Staffing Worksheet," dated 5/26/22, was reviewed. Record indicated (5) Psychiatric problems for Patient 17: Suicidal (act of intentionally causing one's own death)/Self Harm (act of intentionally causing one's own harm), Sexual Victimization (act that is committed or attempted by another person without freely given consent of the victim), Out of Contact with reality (To no longer have a firm or clear understanding of real life; to lose one's ability for clear, rational thought), Assaultive/ Aggressive Behavior (violent, physical actions which are likely to cause immediate physical harm or danger to an individual or others) and Inability to Participate in Programming (Unable to participate in treatments).
However, the records on 6/5/22 showed no documented update for 2 of 5 identified psychiatric problems identified in the Master Treatment Plan which included: (1) Assaultive and (2) inability to participate in programming. Per CNO, it was expected that staff must update and document progress toward goals on each identified problem.

During a review of the facility's policy and procedure titled (P&P) titled, "Interdisciplinary Patient Centered Care Planning" last reviewed on 12/2020, the P&P indicated, Treatment team, including the patient/ family/ representative will complete a review of the treatment plan as clinically indicated, or at a minimum every (7) seven days. Identified problems will be summarized, progress toward goals will be reviewed, new goals and interventions identified, as well as discharge considerations will be updated.

Based on interview and record review, the facility did not adhere to its policies and procedures for two of 30 patients.

This deficient practice resulted in an incident of patient-to-patient assault (an act of inflicting physical harm or unwanted physical contact upon a person) that was not reported to the California Department of Public Health (CDPH, the state department responsible for public health, enforcing some of the laws in the California Health and Safety Codes).

Findings:

During an interview on 6/14/22, at 9:50 a.m., with nurse manager (NM), NM stated, nurses perform patient assessments after an incident, notify MD and patient's responsible party, and report to risk manager (RM) or chief nursing officer (CNO), who determine if the event is reportable to CDPH.

During an interview with Licensed Vocational Nurse (LVN) on 6/14/22, at 10:25 a.m., LVN stated, she has been employed at the facility for two years and had witnessed incidents of patient-to-patient assault. LVN stated, assault is an acute, unexpected event. LVN stated, she assesses patients and their environment after an incident and reports to registered nurse (RN), unit manager, or chief executive officer (CEO).

During an interview with Chief Nursing Officer (CNO) on 6/15/22, at 1:15 p.m., CNO stated, the facility reports to CDPH incidents of assaults that result in significant physical injury.

During an interview with Divisional Director of Clinical Services (DCS) on 6/15/22, at 1:20 p.m., DCS stated, physical abuse occurs to a dependent adult, involves injury or intention of harm, and with premeditation (a plan to commit an act or crime). DCS stated, the facility reports events that result in permanent or serious harm, or require medical care or evaluation. DCS stated, an assault occurs among psychiatric patients with pre-existing concerning or inappropriate behaviors, or with impulsiveness (a sudden act without careful thought).

During a concurrent interview and record review on 6/15/22, at 4:00 p.m., with Chief Nursing Officer (CNO), Patient 2's "Daily Nursing Flowsheet (Nursing Notes)," dated 4/25/22 was reviewed. The Nursing Notes indicated, Patient 2, "Appears to be fixated on roommate (Patient 1) and low risk for danger to others." CNO stated, physical altercations within the facility are primarily a result of impulse, patient's behavior, or disease process.

During a review of Patient 1's "Daily Nursing Flowsheet" (Nursing Notes), dated 4/25/22, the "Nursing Notes" indicated, "Pt (Patient) was hit on side of head by another pt, unprovoked while sitting in group room." The "Nursing Notes" indicated, "Pt (Patient) offered ice bag and transferred to adult II per MD order." The "Nursing Notes" indicated, "Pt vital signs taken and WNL. No complaints of dizziness, headache, nausea, or vomiting." The "Nursing Notes" indicated, "Skin intact, no blood, or broken skin, no swelling at site. Neurocheck (assessment of an individual's neurological functions, motor and sensory response, and level of consciousness) performed and WNL (within normal limits)."

During a review of the facility's policy and procedure (P&P) titled, "Reporting to California Department of Health Services," last revised on 07/2018, the P&P indicated, "Serious patient care incidents may be reported to hospital administration by any patient, visitor, hospital or medical staff. The incidents may include, but are not limited to: elopement, sexual incident, assault, serious medication error, serious adverse drug reaction, suicide, patient deaths within 30 days post discharge, death".