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Based on interview and document review, the facility failed to ensure patient rights to care in a safe setting for 4 of 12 patients reviewed when the hospital failed to provide adequate supervision for violent patients. This resulted in patient injury. This failure had the potential to impact all patients at the hospital, therefore the hospital is found out of compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13. See A144.

Based on interview and document review, the hospital failed to provide care in a safe setting for 4 of 12 patients reviewed (P2, P3) when staff failed to provide adequate supervision, and P3 physically assaulted P2, and P2 sustained a concussion as a result of the assault, and P11 and P12, when staff failed to provide adequate supervision and P12 assaulted P11 until he was unconscious and experienced a concussion and lacerated lip as a result of the assault.

Findings include:

P2 and P3:

P2's medical record review indicated P2 was admitted to the hospital on 1/6/19, with diagnoses that included schizophrenia and psychosis.

P2's Psychiatric Assessment dated 12/14/18, revealed P2 was admitted to the hospital under Rule 20 examination and civil commitment. P2's history included a history of a suicide attempt. P2's treatment plan included frequent observations.

P2's Violence Risk Assessment dated 1/16/19, revealed P1 was assessed by hospital staff as having a moderate risk of violent behavior.

A review of P2's hospital record from a local acute care hospital (Hospital X) dated 2/26/19, revealed P2 was seen in the emergency room as a result of injuries sustained in an assault by another patient. P2 was hit in the head multiple times by a peer. P2's diagnoses after discharge from Hospital X included concussion.

P3's medical record was reviewed and indicated P3 was admitted to the hospital on 2/22/19, with diagnoses that included schizoaffective disorder, bipolar type and substance use disorder.

P3's Psychiatric Assessment revealed P3 was admitted to the hospital under Rule 20 examination and civil commitment. P2's history included felony damage to property, suicide attempt, and physical aggression. P3 was 1:1 staff in jail with maximum segregation. P3's treatment plan included frequent observations due to his history of aggression towards self, peers and staff.

P3's Violence Risk Assessment dated 2/22/19, revealed hospital staff assessed P3's risk for violence as moderate.

A review of P3's therapeutic observation notes dated 2/22/19, revealed P3 was receiving frequent observations (every 5 minutes) by staff for supervision because he had assaulted an inmate while in jail on 2/19/19.

A review of P3's seclusion/restraint record dated 2/26/19, revealed P3 was restrained by staff at 8:05 p.m. because P3 physically assaulted a peer, unprovoked. P3 lunged over staff and other peers, grabbed P2 by the neck and punched P2 in the jaw, putting P2 in a choke hold.

A review of P3's progress note dated 2/27/19, revealed P3 was transferred to another unit due to his aggressive behavior when he severely assaulted a peer the previous evening, which resulted in the peer being sent to the emergency room. A decision was made to start P3 on emergency forced medications (EFM.)

During an interview on 4/12/19, at 8:20 a.m. P2 stated on 2/26/19, a guy was "jumping off the walls" and had started punching him [P2] and ripping out his hair. P2 said he was sent to the emergency room and had been diagnosed with a concussion after the assault. P2 stated he did not feel safe at the hospital, and stated patients there did not seem safe to be around. P2 stated P3 probably got 15 punches in before staff were able to stop the assault. P2 stated it sometimes felt like there were not enough staff to keep the unit safe. P2 stated he had been threatened physically a couple of other times, but had not been attacked physically.

During an interview on 4/12/19, at 9:30 a.m. human services technician (HST)-D stated she was in the day room on 2/26/19, when P3 assaulted P2. She stated there were 5 - 6 other patients in the room, along with another staff person. HST-D described P3 as constantly pacing and swinging his arms and stated P3 intimidated her. HST-D said P3 suddenly lunged at P2, put P2 into a head lock and had started punching P2. HST-D stated she'd called a code green and attempted to pull P3 off P2, but could not physically get P3 off P2. HST-D said when more staff arrived, they were able to intervene and get P3 off P2.

During an interview with a hospital medical provider, s/he stated that P3 came from jail with limited information. P3 was refusing medications in jail, and had not had his hearing for forced medications yet therefore, the hospital could not force medications on the patient unless there was some kind of emergency that warranted the hospital to force medications. Although P3 was psychotic, disorganized, had a recent history of assault and was hallucinating, the hospital staff could not use EFM on the patient.

During an interview with mental health program assistant (MHPA)-E on 4/12/19, at 10:20 a.m. s/he stated that s/he had concerns that the hospital does not have enough staff who can physically intervene for patient safety. S/he stated s/he did not feel the hospital had the right numbers and mix of staff.

During an interview with registered nurse (RN)-F on 4/12/19, at 10:32 a.m. s/he stated s/he was there the evening P3 had attacked P2. RN-F stated s/he attempted to assist HST-D to get P3 off P2, but P3 struggled with them and continued to punch P2. RN-F stated s/he did not feel always feel safe. RN-F stated s/he had been at the hospital for about 1.5 years and in that time the patient population had become more acute and violent.

During an interview with a medical provider, s/he stated the hospital population was changing and it had become more of a forensic hospital. The medical provider also stated having criminals in the population was new and very challenging. "Sometimes the hospital gets very vulnerable patients", and s/he struggles with if they are safe with the current population. S/he stated s/he agreed that staff do not feel safe at the hospital.

During an interview with administrative staff s/he stated the facility staff do not feel safe at the hospital. The patients in the hospital are very sick, and some have killed people, and the hospital needs help.

When queried about the current patient population, administrative staff provided the following statistics: There were 51 patient injuries requiring some kind of intervention related to patient to patient assault from December 2018 - April 5, 2019. The facility averages about 25 patient to patient assault incidents per month.

The policy Therapeutic Observations dated 4/2/19, directed: Policy: Mental Health and Substance Abuse Treatment Services staff will provide for the safety of clients whose clinical presentation warrants additional supervision, observation and/or restricted access to potentially dangerous items. The level of observation, supervision of restriction will be the least restrictive or intrusive necessary.

P11 and P12:

P11's medical record was reviewed and revealed P11 was admitted to the hospital on 3/29/19, with diagnoses that included traumatic brain injury with neurocognitive problems, and behavioral disturbances.

P11's Psychiatry Assessment dated 3/29/19, revealed P11 was admitted from a community behavioral health hospital (CBHH) due to the need for a higher level of service related to aggressive behavior posing a risk to himself and others. P11 was on civil commitment, with court authorized electroconvulsive therapy (ECT). P11 had experienced increasingly problematic behavior in the last year including yelling, threatening others and throwing items. CBHH staff indicated most if not all other individuals on the CBHH unit were frightened given his impulsive, aggressive and threatening demeanor. P11's supervision plan included 1:1 staffing when he was out of his room.

P11's Violence Risk Assessment dated 3/29/19, revealed P11 was assessed by hospital staff as being at moderate risk for violence.

P11's hospital record from a local acute care hospital (Hospital X) dated 4/3/19, revealed P11 was seen in the emergency room for a closed head injury and complicated laceration of the lip.

Medical record review revealed P12 was admitted to the hospital on 3/5/19, with diagnoses that included schizophrenia and substance abuse disorder. P12 was civilly committed, and had a court order for forced medications.

P12's Psychiatry Assessment dated 3/5/19, revealed P12 had a history of assaulting others, "His difficulties are often hallmarked by a high degree of impulsivity with a notable level of dangerousness in terms of harm to self and threats to harm others and in fact has an extreme history of assaulting others." P12's supervision plan included frequent observations (every 5 minutes.)

P12's Violence Risk Assessment dated 3/5/19, revealed hospital staff assessed P12 as a moderate risk for violence.

An incident report dated 4/3/19, at 1:49 a.m. revealed P11 asked for cigarettes and started banging on the nursing station window, yelling and threatening staff when he did not get them. P12 came out of his room and placed his hand around P11's neck, choked him and began punching P11 several times while P11 was on the floor. P12 then stood up and walked back to his room. P11 was unconscious on the floor and had a lacerated lip.

During an interview with HST-H on 4/15/19, at 2:35 p.m. she stated she was P11's 1:1 staff the night of the assault. HST-H stated she was behind the glass at the nursing station when the assault happened. She was unable to intervene immediately as she was behind the glass at the nursing station and the assault happened so quickly. She stated the policy for a distant 1:1 includes that staff have to keep the patient within sight, which she was doing, through the glass of the nursing station.

The policy titled Therapeutic Observations dated 4/2/19, directed under Definitions: Distant 1:1 Observations: - staff assigned will keep the client within range of view at all times.