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Based on observation, interview, and record review, the hospital failed to keep patients safe from abuse for of 2 of 18 patients (P16, P18) reviewed for abuse when interventions were not initiated to prevent physical aggression. P18 attacked P16 on 5/25/25 and on 5/31/25. In addition, the hospital failed to timely report the allegations to the state agency when the incident of 5/25/25 was not reported until 5/28/25 and the 5/31/25 incident was not reported until 6/2/25.

As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.13.

An immediate jeopardy was issued at A-0145. See A-0145 for additional information.

A condition level deficiency was issued at A-0144. See A-0144 for additional information.

A standard level deficiency was issued at A-0143. See A-0143 for additional information.

49618


Based on interview and record review, the facility failed to protect a patient's personal information for 1 of 18 (P12) patients when hospital staff informed law enforcement of the patient's presence in the hospital. Hospital staff informed law enforcement of P12's presence in the hospital after being notified that he had an active warrant out for his arrest.

Findings include:

P12's medical record was reviewed. P12 was admitted to the hospital on 12/29/23 due to stroke symptoms. P12 was diagnosed with an acute ischemic left middle cerebral artery stroke with moderate expressive aphasia and severe receptive language impairment and resolved right hemiparesis. P12's additional diagnoses included cerebral edema and asymptomatic petechial hemorrhages, hypotension, ischemic cardiomyopathy, diabetes mellitus, methamphetamine abuse, suicidal ideation and depression, homelessness, and history of noncompliance with medications. P12 was discharged from the hospital on 1/18/24 when he transferred to the county jail.

P12's progress note dated 1/10/24 indicated P12's transitional barrier was placement in an assisted living facility.

P12's progress note dated 1/11/24 indicated P12's transitional barrier was placement in an assisted living facility.

P12's progress note dated 1/12/24 indicated P12's transitional barrier was placement in an assisted living facility.

P12's progress note dated 1/15/24 indicated P12's transitional barrier was placement in an assisted living facility.

P12's progress note dated 1/17/24 indicated P12's transitional barrier was placement due to P12's criminal history.

P12's progress note dated 1/18/24 indicated on 1/18/24, case management was made aware that P12 had a warrant out for his arrest in the county. P12 was released to custody of the police department on 1/18/24.

P12's progress note dated 1/18/24 indicated P12 was medically ready for discharge since 1/11/24. After a discussion with care management leadership and law enforcement personnel, the patient would be released with law enforcement who was at P12's bedside.

P12's progress note dated 1/18/24 indicated social services (SS)-A had noted P12's transitional barriers included placement. SS-A had followed up with pending long term care referrals and was awaiting responses back. SS-A consulted with law enforcement to coordinate the P12's discharge to law enforcement custody. P12 was discharged to law enforcement custody.

During an interview on 6/4/25 at 11:23 a.m., registered nurse (RN)-D stated case management was attempting to find placement into an assisted living facility for P12. Case management would send referrals out to facilities and the facilities would review the referral. One of the facilities reported back to her that they ran a criminal background check on P12, and it came back that P12 had an active warrant for his arrest. P12's active warrant was a barrier to finding long term care placement. RN-D stated the facilities wanted the hospital "to explore the warrant". RN-D spoke with the hospital security guards to identify what steps to take, what information they should share, and what information they could not share. The hospital security guard could not be identified. The security guard recommended to call the county law enforcement to see if they could drop the criminal charge so P12 could find placement, and the county law enforcement stated they would not drop the criminal charge. RN-D stated she could not recall if she called the county law enforcement or if the social worker did. RN-D stated when it comes to Health Information Portability and Accountability Act (HIPAA), the hospital does not give patient's identifying information out to people who are not involved in the care with that patient. The county law enforcement was not involved in P12's medical care. RN-D stated if law enforcement is not involved in a patient's medical care, the patient's information should not be shared with them.

During an interview on 6/4/25 at 1:03 p.m., security officer (SO)-B stated if a patient has an active search warrant, law enforcement should not be called while the patient is receiving care in the hospital. If the hospital is attempting to find long term care placement for the patient, the patient is still receiving care in the hospital.

During an interview on 6/4/25 at 1:20 p.m., Regulatory and Accreditation Program Manager (RAPM) stated legal or criminal information should not apply when a patient is receiving medical care in the hospital.

During an interview on 6/4/25 at 3:15 p.m., Regulatory and Accreditation Officer (RAO) stated criminal or legal information should not be shared with law enforcement while a patient is receiving medical care in the hospital.

During an interview on 6/5/25 at 7:27 a.m., RN-H stated two law enforcement officers came to the unit P12 was on and asked if P12 was in his room. RN-H stated she could not give that information to law enforcement. Law enforcement stated P12 had a warrant out for his arrest, and they had to take P12 into custody. RN-H talked to case management but could not recall the specific case management staff she talked to. Case management stated P12's discharge plan was being changed from long term care placement to law enforcement custody. Once RN-H was told P12 was being discharged to law enforcement custody, she brought the law enforcement personnel to P12's room. RN-H printed off P12's after visit summary and gave it to the patient, and then the patient gave the packet to the law enforcement personnel. RN-H stated it is not "appropriate" for hospital staff to disclose patient information specific to the care they receive, and diagnosis, or if the patient is in the hospital. RN-H stated when it comes to HIPAA, it is not appropriate for hospital staff to contact law enforcement about a patient's who has an active warrant.

During an interview on 6/5/25 at 10:39 a.m., SS-A during P12's admission, SS-A and his care team would send out referrals to facilities for long term care placement. SS-A would get refusals back from facilities because P12 had an active warrant out for his arrest. RN-D called the county law enforcement, and the county law enforcement stated they were going to "book" P12 and follow up on his warrant. SS-A stated that because P12's warrant was in another county, the local county law enforcement was going to pick up P12 from the hospital. SS-A stated she did not know the policy on HIPAA and patients with active warrants.

The hospital's Release of Information policy dated 6/2023 indicated a permitted release of information disclosure was civil, administrative, or criminal proceedings or actions.

The hospital's Patient Privacy and Confidentiality policy dated 3/2025 indicated hospital employees, clinical partners, students, and volunteers would maintain privacy and confidentiality for all patients and would agree to reasonably cooperate with the hospital regarding any issues related to patient privacy and confidentiality. Protected Health Information included all information regarding patients; their presence in the facility if requested, their condition, care, or treatment, whether in the medical record, in computer files, transmitting or receiving data via the e-health exchange, or other related types of data. Protected Health Information about patients which is obtained by hospital employees, clinical partners, volunteers, or students is presumed to be private and is shared only for appropriate professional purposes, only at the time it is needed and with those who have a legitimate need to know.

Based on interview and document review, the hospital failed to provide adequate monitoring and supervision to prevent 1 of 1 patient reviewed (P4) from self-injurious behavior and ingesting foreign objects when the implementation of interventions were not successful. P4 had three instances of ingesting of foreign object which required surgical interventions.

Findings include:

P4's medical record was reviewed. P4 was admitted to the medical unit on 5/15/25 for evaluation of self-inflicted abdominal wound. P4's diagnosis included significant psychiatric history, including borderline personality, polysubstance abuse, suicidal ideation, and self-harming behavior.

P4 was admitted to the facility on 5/15/25, for medical treatment of self-inflicted abdominal wound. P4's diagnosis at admission included suicide and self-inflicted injury by cutting and piercing instrument, borderline personality disorder and history of swallowed foreign body. Admitting provider notes included the following, review of P4's treatment plan with no male caregivers. P4 had a long history of swallowing objects and a suicide attempt to hang herself in the hospital. The provider discussed with psychiatry and did not order one-to-one or suicide precautions at the time of review. P4 denied suicide ideation and requested a 72-hour hold, which was deferred to psychiatry.

A Vulnerable Adult Maltreatment Report dated 5/15/25 was submitted by the hospital outlined P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Patient being evaluate for decision-making capacity by psychiatry. Patient was seen by psychiatry at 12:20 p.m. Psychiatry exited the room to speak with nursing. Decision was made to place patient on suicide precautions including 1:1 sitter observation. Staff returned to room within 5 minutes of provider leaving to begin removal of items, environment of care check and 1:1 nursing. Patient told nursing to check something on counter in room. When nursing turned back on patient, patient swallowed two AA batteries from bedside remote control. Actions taken to protect the vulnerable adult from further harm included additional environment of care check to remove all items that have potential to swallow, and modification of 1:1 always includes eyes on patient. Seeking emergency guardianship.

An Esophagogastroduodenoscopy (EGD) report dated 5/16/25, at 4:06 p.m. indicated after obtaining informed consent from P4, the endoscope was passed under direct vision two AAA batteries were found in the gastric fundus. Removal was successful. Pt transported to the ICU for sedation. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well.

A facility incident report dated 5/16/25, indicated P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Patient being evaluate for decision making capacity by psychiatry. Patient was seen by psychiatry at 12:20 p.m. Psychiatry exited the room to speak with nursing. Decision was made to place patient on suicide precautions including 1:1 sitter observation. Staff returned to room within 5 minutes of provider leaving to begin removal of items, environment of care check and 1:1 nursing. Patient told nursing to check something on counter in room. When nursing turned back on patient, patient swallowed two AAA batteries from bedside remote control.

A nursing note dated 5/27/25, at 10:37 p.m., indicated P4 reported abdominal pain because she swallowed metal wire earlier this AM as she was "frustrated at the time." P4 also notified staff that she had multiple screws in pillowcase. She attempted to remove metal objects from couch first, was unsuccessful so then moved to chair to find metal objects to remove, which was done "a couple of days ago". P4's pillowcase was removed, and she voluntarily provided the screws. Room stripped of all additional removable objects/pieces by charge RN. Explained to P4 and 1:1 sitter that hands must always be visible. Notified cross-cover MD of above information. Ordered abdominal CT, completed this evening. CT completed with writer, 1:1, and house float RN for support. Report given to oncoming RN.

A nursing note dated 5/28/25, at 3:46 a.m. indicated P4 had just received a CT scan due to ingesting a foreign metal object. Writer communicated with patient that she would not be allowed to leave her room overnight due to her ingesting the foreign object. Explained to patient that room restriction would be further discussed with the care team in the morning. P4 agreed to these boundaries. Charger nurse present when conversation occurred as well as 1:1. Charge nurse communicated to the surgical care unit director. GI was consulted for EGD in the morning to remove the foreign body from stomach. P4 was alert and oriented to person, place, time, and event. Staff 1:1 remains in place due to risk for self-harm and elopement. P4 did have complaints of abdominal pain.

An Esophagogastroduodenoscopy (EGD) report dated 5/28/25, at 10:19 a.m. indicated after obtaining informed consent, the endoscope was passed under direct vision. A longitudinal piece of twist ties extending into the bulb was found in the gastric antrum. Removal was accomplished with a snare. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well.

A facility incident report dated 5/28/25, indicated P4 Patient w/significant psych history including swallowing metal objects with 1:1 sitter present in room reported that she swallowed a metal wire earlier in the day, believes it was sometime between 0700-0900, because she was frustrated. Reports that she got the wire from the chair while 1:1 sitter was in the room, as well as swallowing it while sitter in the room. At that time also reported that she had screws hiding inside her pillowcase, reports all objects were obtained 2 days prior to event happening. Disclosed that she was able to get objects by hiding hands behind a pillow while sitting in chair and unscrewing from wall/chair/nearby objects. Notes that all of this was done while 1:1 was present in room. CT obtained confirmed that metal object was in her stomach, GI consult placed for removal.

A Vulnerable Adult Maltreatment Report dated 5/28/25 was submitted by the hospital outlined P4 admitted 5/15/2025 following multiple admissions for open wound of abdomen. Upon evening assessment on 5/27/25, patient endorsed pain and reported that pain is because she swallowed metal wire earlier this AM., she did this because she was "frustrated at the time." Per patient report, all of this was done "a couple of days ago". Imaging confirmed foreign object. Foreign object obtained via endoscopy 5/28/25. Actions taken to protect the vulnerable adult from further harm included room stripped of all additional removable objects. Maintenance completed additional environmental check. Modification to unique treatment plan for out of room activity. Explanation to patient and 1:1 sitter that hands must always be visible. Seeking emergency guardianship.

A nursing note date 5/30/25, at 11:56 a.m. indicated P4 extubated as ordered after afebrile and all tests showed no infection at this time. P4 to room air. Instantly accusing staff of trying to kill her and watch her choke. P4 was fighting the ventilator and coughing as the sedation was weaned waiting until extubation. P4 consistently asking for court decisions and guardianship and demanding staff be fired. P4 demanding to be left restrained while in the hospital, soft wrist restraints in place for safety at this time until transferred out of ICU to a safer environment and two available sitters.

A nursing note dated 5/30/25, at 3:53 p.m. indicated P4 would be transferred back to the medical surgical unit with two nursing assistant (NA) sitters present for safety. Both were given report previously by charge nurse. Behavioral Access RN present on the unit for transfer along with nursing supervisor.

A nursing note dated 6/1/25, at 7:49 a.m. indicated P4 swallowed a wire and some water. Situation explained and both sitters that were present. They stated P4 was getting frustrated that the staff wanted to measure the water that she was allowed to swish and spit and was upset about needing some lights on to observe her. She started raising her voice and becoming more agitated, so one sitter went to open the room door and put the assistance light on, while the other sitter observed her walk to the bathroom and drink the water while she was scratching at her breast. Then P4 stated she hid the wire underneath her breast fold. P4 did not disclose where she got the wire. She laughed at the situation and wondered if she told us where she got it, she could have more privileges. Security called to complete a room search. Primary RN called provider. Completed environmental checklist more frequently. Removed items sitting outside of room that could be snatched easily. During the search, P4 was hyperactive and making sexual comments- inquiring if we would search her body. Stated "I'd love to strip for you, you can search me all you want" and proceeded to pull pants down and cough and flashed her breast folds and abdominal folds. P4 was told "That is inappropriate, please stop, but at some point, a search may be necessary for your safety." Sitters re-educated on close, careful observation, and always both keeping eyes on pt and staying in the room. Educated them that they could use the staff assist, or personal alarm. Updated director and nurse supervisor.

An Esophagogastroduodenoscopy (EGD) report dated 6/1/25, at 10:27 a.m. indicated after obtaining informed consent from P4, the endoscope was passed under direct vision. A long piece of a metal wire (extracted from a surgical mask per patient) was found in the stomach, and extracted. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well.

A provider note dated 6/1/25, 1:09 p.m. provided P4's history. P4 left against medical advice (AMA) on 05/04/2025 afternoon but returned several hours later with profuse drainage and food coming out from the abdominal wound. Per surgical team, patient's abdomen was inoperable. Patient on strict nothing by mouth (NPO) (okay for medications), started on total parenteral nutrition (TPN) nutrition. Patient left AMA again on 5/14/2025 after she was refused IV Dilaudid and returned few hours later and admitted on 5/15/2025. Patient was intubated after the procedure and observed in ICU, successfully extubated on 5/17/2025 and monitored at surgical progressive care unit (SPCU). Guardianship was being pursued to help make decisions regarding her care and find compliance with the necessary interventions for her safety. On 5/28/2025 patient ingested twisted tie, requiring removal via EGD. Intentional foreign objects ingestions included patient ingested 2 AAA batteries from remote on 5/16/2025, requiring EGD removal, ingested twisted tie on 5/28/2025, removed per EGD, and ingested twisted tie on 06/01/25, removed per EGD.

A nursing note dated 6/1/25, at 1:14 p.m. indicated P4's endoscopy had been completed at 10:30 a.m. for foreign body removal. P4's behavior was acceptable prior to procedure. Remains on 2:1 nursing at all times. Procedure was successfully completed. P4 threatened to dismantle computer and did attempt to pull cords out of the wall. Security and behavioral health arrived to redirect. Several methods were used to calm patient down. She then removed her port access. P4 then placed herself on the floor. She banged herself, her head on the floor, bed, and cupboards. Order obtained for physical restraints. P4 was placed on the bed by staff. Security, nursing staff, and behavioral health remained in room to try to calm patient down verbally. P4 redirection of behavior became unsuccessful. Placed in 4-point restraints. 2:1 nursing remains present. Will remain closely monitored.

A Vulnerable Adult Maltreatment Report dated 6/1/25 was submitted by the hospital outlined P4 swallowed a piece of metal that she took from a surgical mask that was laying in the garbage. Actions taken to protect the vulnerable adult from further harm included patient room has been stripped of all harmful objects. 2:1 sitter in place. Frequent environmental checks.

During an interview on 5/29/25 at 10:94 a.m., RN-B stated P4 had a history of self- injurious behavior and ingestion of foreign objects which required staff to always be in the room with P4. P4 required 1:1 staffing for her safety. P4 swallowed a wire on 5/27/25, which was removed successfully thru a surgical procedure. Staff were to always have eyes on P4; however, staff had no knowledge that P4 swallowed anything until P4 reported this to staff. P4 was currently in ICU intubated and sedated for her safety.

During an interview on 5/29/25 at 12:21 a.m., medical doctor (MD)-A stated she was very familiar with P4's medical diagnosis and conditions. Provider orders had been in pace which included 1:1 sitter for P4's safety. Her expectation was staff always had eyes on P4. She was not surprised P4 continued to ingest foreign object, however she would still expect staff to follow all provider orders for P4's safety. MD-A stated P4's case of self- injurious behavior and ingestion of foreign objects behaviors is the most severe case she has treated.

During an interview on 6/2/25, at 8:41 a.m. Chief Nursing Officer (CNO) stated P4 had again ingested a piece of metal from a medical face mask that required surgical removal. At the time of the third ingestion incident P4 had two sitters in the room with her. CNO stated the hospital was still investigating the incident.

During an interview on 6/2/25 at 9:18 a.m., NA-C stated she was assigned as 1 of the 1:1 sitters for P4, always having eyes on P4. It was important to always watch P4 and make sure they are staying safe. She was assigned as P4's 1:1 prior to the ingestion on 5/27/25, and many times P4 would be laying on the couch where you could not see her hands and face. NA-C stated nursing staff did not share a lot of information or give instruction for performing the 1:1 prior to the incident on 5/27/25, including that you had to always see P4's hands and face.

During an interview on 6/2/25, at 10:34 a.m. RN-B stated P4 transferred back to the surgical unit on 5/30/25. Interventions were in place to include all items removed from the room that could be removed and possibly ingested. P4 was also always assigned two staff in the room with her. Staff were to always have eyes on P4, including a visual of P4's face and hands. P4 disclosed to staff she took a face mask out of the garbage which had been thrown away by the IV access team. There was a failure of something because no one saw P4 take the mask from the garbage. Staff should have seen P4 remove the mask from the garbage. After the incident, all garbage is to be taken out with the staff after the care has been performed. The entire team met including the behavioral nurse, primary medical doctor, charge nurse, and psychiatric team to review P4's orders and care plan. RN-B stated immediately after the incident re- education all staff on the importance of eyes on at all times, no garbage or items are to be left in the room and environmental room checks were initiated. P4 has not had any additional ingestion incidents since.

The hospital policy titled Sitter and Video Observation, dated 2/2025, indicated a Sitters responsibility included the remain with patient and always ensure visibility and patients on suicide precautions will have head and hands visible. Sitter is staff trained to observe for real or potential threats to patient and staff safety.

Hospital's Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated caregiver neglect means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the vulnerable adults' s physical or mental health or safety.

49618


Based on observation, interview, and record review, the hospital failed to keep patients safe from abuse for of 2 of 18 patients (P16, P18) reviewed for abuse when interventions were not initiated to prevent physical aggression. P18 attacked P16 on 5/25/25 and on 5/31/25. In addition, the hospital failed to timely report the allegations to the state agency when the incident of 5/25/25 was not reported until 5/28/25 and the 5/31/25 incident was not reported until 6/2/25.

The immediate jeopardy began on 5/25/25, when P18 physically attacked P16, and the facility failed to ensure intervention were in place to prevent further physical aggression towards P16 or other patients on the mental health unit. Then again, P18 physically attacked P16 on 5/31/25. The Regulatory and Accreditation System Program Manager and Chief Nursing Officer was informed of the immediate jeopardy on 6/3/25 at 4:31 p.m. The immediate jeopardy was removed on 6/5/25 at 10:09 a.m. but noncompliance remained at a condition level.

Findings include:

A Vulnerable Adult Maltreatment Report dated 5/28/25, was submitted by the hospital. The report outlined on 5/25/25, at 7:43 p.m. P-16 was seen in the dining room in a headlock by P18. Staff guided P18 away from P16, but P18 attempted to go towards P16 again, grabbing and attempting to punch P16. Staff guided P16 to her room. Per P16 report, the attack was unprovoked and has no idea why she was attacked by P18. P16 reported she and P18 had been arguing over the remote, and P16 stated "beat me up". P16 was bitten by P18; suffered a laceration on right side of forehead. Wound was cleaned and image was uploaded to P16's medical chart. After wound was cleaned P16 requested to go back to the dining room to finish coloring. Security came onto unit to interview with P16 and inquire if she wanted to press charges against P18.

On 6/3/25, during video review with security guard (SG) on 5/25/31, at 7:42 p.m. P16 was seen seated at a table in the dining room of the mental health unit. P18 approached P16 while she was seated at the table and began striking P16 multiple times in the face and head and pulling P16's hair. P18 bit P16 on the right forehead causing a laceration. No staff was present in the dining room at the initial time of the attack. P18 and P16 were separated by staff, however they remined in the same area on the mental health unit (MHU).

A facility report dated 5/25/25, indicated on 5/25/25, at 7:43 p.m., P16 was seen in the dining room in a headlock by P18. Staff guided P18 away from P16, but P18 attempted to go towards P16 again, grabbing and attempting to punch P16. The report lacked interventions to prevent further incidents of physical violence and aggression.

A Vulnerable Adult Maltreatment Report dated 6/2/25, was submitted by the hospital. The report outlined on 5/31/25, at 5:55 p.m. P16 had been showing signs of agitation such as irritability throughout the day as evidenced by door slamming and notes including the progress note from the physician earlier that day. At 5:50 p.m. P16 barricaded herself and another patient in the dining room at 5:52 p.m. P16 did open the doors and walked back to her room prior to returning to the dining room with her meal tray. At 5:55 p.m. P18 entered the dining room walking directly towards P16, grabbed P16 by the hair with bilateral hands and brought P16 to the floor. P18 did hit P16 in the head 3-5 times before being pushed back against the wall. At 5:55 p.m. staff were hands on. The behavioral alarm was initiated, and security contacted. At 5:55 p.m. security officers were on site in the dining room. P16 was accepting of oral Zyprexa. P18 verbally redirected successfully. Staff will continue to assess and monitor all patients for changes in risk level.

On 6/3/25, during video review with security guard (SG) from 5/31/31, at 5:50 p.m., P16 had physically barricaded herself and 2 other patients in the dining room. No staff was present in the dining room, and no staff member entered the dining room to redirect or remove P16 from the situation. At 5:55 p.m. P18 entered the unit dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and threw P16 to the floor. P18 violently struck P16 with both her fists striking her head and face at least five times before staff pulled P18 off P16 who was lying on the floor during the entire physical attack. No staff was present in the dining room at the initial time of the attack. Staff verbally redirected P18 successfully. P16 was transferred onto the BICU for safety.

A facility report dated 6/3/25, indicated on 5/31/25, at 5:50 p.m., P16 had physically barricaded herself and 2 other patients in the dining room. At 5:55 p.m. P18 entered the units dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and brought P16 to the floor. P18 struck P16 in the head 3-5 times before being pushed back against the wall. P16 was moved to onto the BICU for safety.

P16's medical record was reviewed. P16 was admitted to the mental health unit (MHU) from the hospital's emergency department on 5/23/25. P16's diagnosis included suicidal ideation, schizoaffective disorder, and antisocial personality disorder. Care/treatment plan included risk of violence towards self/other, and cognitive perceptual pattern impaired.

P16's behaviorally anchored rating scale (BARS) assessment dated 5/23/25, indicated P16 scored a four, indicating quiet and awake and was determined to be a low-risk violence. The assessment also indicated to consider assault precautions and aggression prevention protocol. Assault precautions were initiated, however P16 remained on routine (15 min) safety checks.

A nursing note dated 5/25/25, at 11:02 p.m. indicated P16 was seen in the dining room in a headlock by a peer. Staff guided peer away from patient, but peer attempted to go towards patient again, grabbing and attempting to punch patient. Staff guided patient to her room. Patient states that the attack was unprovoked and has no idea why she was attacked by her peer. Per spell out (BHT) report, patient and peer were arguing over the remote, and patient stated, "beat me up". Patient was bitten by peer; had laceration on right side of forehead. Wound was cleaned and image was uploaded to patient chart. No changes were made to P16's observation level and or interventions. P16 remained on routine (15 min) safety checks.

P16's provider note dated 5/27/25, at 5:46 p.m. at 7:35 p.m. indicated there were concerns known for violence towards others, including violence in a healthcare setting. P16 remained on routine (15 min) safety checks.

P16's nursing note dated 5/28/25, at 3:05 p.m. indicated P16 walking very close to other patients and making comments as she goes by. Patient stated, she is agitated. P16 remained on routine (15 min) safety checks.

A nursing note dated 5/28/25, at 4:45 p.m. indicated P16 became agitated and began screaming in dining room. Security called for show of support. Intramuscular (IM) Zyprexa administered in left arm at 3:50 p.m. Patient was asked to remove the 10+ pens from her hair and pockets. She continued to scream but ultimately gave them up to staff. Paced around milieu uttering "you don't want to f*ck with me" and screamed through the BICU doors to the other patients. Eventually returned to dining room to isolate with doors closed. Security remained on unit until 4:45 p.m. No changes made to P16's care/treatment plan, P16 remained on routine (15 min) safety checks.

A nursing note date 5/29/25, at 12:38 p.m. indicated P16 isolating to self, requiring intermittent reminders from staff to have appropriate physical boundaries with peers on the unit. Patient was overall redirectable. Patient remained free from violence this shift, occasionally yelling out to peers and staff from room. Remained on the adult mental health unit for further monitoring and stabilization. P16 remained on routine (15 min) safety checks.

A nursing note date 5/29/25, at 5:10 p.m. indicated P16 walked past peer and raised middle finger at another patient, staff told patient that was not nice. P16 walked past peer again and flicked peer in the forehead, attempted to flick another peer and staff. P16 was told they were not allowed to touch peers. P16 slammed door, went into dining room, and shut dining room doors. P16 remained on routine (15 min) safety checks.

A nursing note dated 5/29/25, at 5:24 p.m. indicated P16 walked past peers and flicked them off. P16 then went into the dining room and closed both doors. P16 remained on routine (15 min) safety checks.

A nursing note dated 5/29/25, at 10:09 p.m. indicated P16 was flat and agitated. Occasionally yelling out, had poor boundaries with peers that required intermittent reminders from staff to have appropriate physical boundaries with peers on the unit. Patient took markers from another peer, was dismissive, and denied psych questions. Possibly responding to some internal stimuli. P16 remained on routine (15 min) safety checks.

A nursing note dated 5/30/25, at 8:53 a.m. indicated P16 was observed yelling out with all interactions this AM. Pacing and slamming room door. No changes to P16's observation level or care plan made. P16 remained on routine (15 min) safety checks.

A nursing note dated 5/31/25, at 7:47 p.m. indicated P16 barricaded herself and another patient in the dining room. Later, P16 ate dinner at dining room table. Patient was on the floor on her back after another patient pulled her hair and punched her in the face. The two patients were separated, removing P16 from the room. P16 went to her room, vitals were taken, a small bump to left outer eyebrow was present. Police department contacted and she was interviewed. Security present for show of support. Patient escorted back to BICU with security present. P16 took her personal belongings and went back to the BICU without difficulty.

P18's medical record was reviewed. P18 was admitted to the MHU from the hospitals Empath (Emergency Psychiatric Assessment, Treatment and Healing) unit on 5/20/25. P18's diagnosis included history of schizoaffective disorder, bipolar type, borderline personality disorder, and alcohol use disorder. P18's care/treatment plan included risk of violence towards self/other, and cognitive perceptual pattern impaired.

A nursing note dated 5/24/25, at 9:59 p.m. indicated P18 stated she was hearing voices that are threatening to harm her, was feeling anxious and afraid. She did not want to be in her room alone. P18 remained on routine (15 min) safety checks.

A nursing note dated 5/25/24, at 9:47 p.m. indicated at 7:43 p.m. P18 was observed in the dining room getting up and putting peer in a headlock, trying to hit peer. Staff guided patient away from peer. Patient did not resist staff but attempted to go towards peer again and grabbed peer. Staff guided patient to her room. P18 remained on routine (15 min) safety checks.


A provider note dated 5/26/25, at 7:56 a.m. indicated P18 physically assaulted a peer after getting into an argument about the TV remote. She put the peer in a headlock, attempted to punch her and bit her. She reported that she was experiencing auditory hallucinations that were "egging" her on. P18 remained on routine (15 min) safety checks.

A provider note dated 5/27/25, at 4:03 p.m. indicated P18 had significant volatility and significant physical aggression with another patient over the weekend biting this patient on the head breaking the skin. This was over a fight over the remote control. Patient later told staff that she was having auditory hallucinations although this is somewhat unclear and there were concerns about this being behavioral and part of the patient's personality style. P18 remained on routine (15 min) safety checks.

A provider note dated 5/30/25, at 3:33 p.m. indicated P18 endorsed ongoing struggles with auditory hallucinations, particularly at night, reporting the voices "come out for me at night" and she has to "fight for [her] sanity." She described the voices as severe last night, contributing to a disrupted sleep schedule. P18 remained on routine (15 min) safety checks.

A nursing note dated 5/31/25 at 6:26 p.m. indicated P18 abruptly went into the dining room and pulled the hair of another peer. While pulling the peers hair she brought her to the ground. Once on the ground she started punching her in the face/head approximately four to five times. At this time, another peer intervened and pushed and pulled her off the other peer. P18 said when she saw this peer it was an "impulse." She said she grabbed her hair and felt like she "blacked out."

P18's BARS assessment dated 5/31/25, indicated P18 scored a seven-meaning violent, requires restraint. The assessment also indicated high aggression risk and were to consider assault precautions and aggression prevention protocol. Assault precautions were initiated, however P18 remained on routine (15 min) safety checks.

A provider note dated 6/1/25, at 11:01 p.m. indicated P18 was involved in a physical altercation yesterday after another patient accused her of stealing a notebook. She acknowledged they fought in the past but believed the issue resolved. When the accusation was made again, she became upset and responded by pulling the other patient's ponytail and punching her in the face. She denied any command auditory hallucinations directing her to act violently and expressed remorse for the incident afterward.

During an interview on 6/3/25 at 1:12 p.m., Registered (RN)-A stated there had been two sperate incidents of physical aggression/assault involving P16 and P18 on the inpatient Mental Health Unit. He had not reviewed video footage of either incident until 6/3/25. Both incidents occurred in the dining room, with no staff present. Video review of the incident revealed P18 approached P16 while she was seated at the table and began striking P16 multiple times in the face and head as well as pulling P16's hair. P18 bit P16 on the right forehead causing a laceration. RN-A stated after the incident occurred on 5/25/25, no changes to either P16 or P18's observation level had been made and they both remained on the same unit with routine 15 min safety checks. RN-A stated on 5/31/25, P16 had barricaded herself and two other patients in the dining room prior to the assault incident between P18 and P16. No staff was in the dining room while P16 barricaded herself and two other patients in the dining room. The assault on 5/31/25, involving P18 and P16 was very rough and physically aggressive. The video had revealed P18 entered the unit dining room and walked directly towards P16 who had been seated at a table. P18 grabbed P16 by her hair with both hands and threw P16 to the floor. P18 violently struck P16 with both her fists striking her head and face at least 5 times before staff pulled P18 off P16 who was lying on the floor during the entire physical attack. No staff was present in the dining room at the initial time of the attack. RN-A stated after P18 had physically assaulted P16, P16 was moved onto the BICU. P18's treatment /care plan upon admission identified patient care area concerns, which included behavior altered, ineffective coping, and violence/self/others.

During an interview on 6/4/25, at 1:35 p.m. RN-F stated if there was an incident of patient-to-patient physical aggression assault we would want to separate and obtain and order for a sitter for 1:1 observation. If able to only get one staff for the 1:1 the aggressor is the one who would be assigned a sitter for that patient and or removed from the unit and placed on the BICU. It was important to separate and increase the observation level to prevent further altercations not only for that patient's safety if they are being targeted, but also for the other patients on the unit. After the initial incident which occurred between P18 and P16 on 5/25/25, no changes to either patients' observation level were put in place for patients' safety.

During an interview on 6/4/25, at 2:18 p.m. RN-A stated the first incident of patient-to-patient aggression between P16 and P18 had occurred on 5/25/25, at 7:43 a.m. however it was not reported to the state agency until 5/28/25, at 6:20 p.m. RN-A stated the second incident of patient-to-patient aggression between P16 and P18 had occurred on 5/31/25, at 5:55 p.m. however it was not reported to the state agency until 6/2/25, at 10:00 a.m. RN-A stated anyone of the staff are able to file the required repot and education for all staff was needed to ensure the hospital met the timelines and guideline for reporting.

Hospital Inpatient Mental Health Units Patient Outcome Standards policy dated 10/2024, indicated patients on the MHU can expect the following outcomes, to remain physically and emotionally safe, behavioral complications to be monitored and intervention provided as indicated, to remain physically and emotionally safe.

Hospitals MHUs Safety and Security policy dated 3/2024, indicated the purpose of the policy is to ensure a safe, secure environment for all patients and staff. Patients who are in imminent danger to themselves or others will be protected by appropriate interventions.

Hospital's Vulnerable Adult (VA) Maltreatment policy dated 2/2025 indicated caregiver neglect means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to food, clothing, shelter, healthcare or supervision which is reasonable and necessary to obtain or maintain the vulnerable adults' s physical or mental health or safety.

Hospitals Rights and Responsibilities of Patients policy dated 11/2022, indicated patients shall be free from maltreatment as defined in the Vulnerable Adult Protection Act. "Maltreatment" means conduct described in Section 626 .5572, Subdivision 15, or the intentional and nontherapeutic infliction of physical pain or injury, or any persistent course of conduct intended to produce mental or emotional distress.

The immediate jeopardy that began on 5/25/25, was removed on 6/3/25/25, when it was verified by interview, and document review the facility completed review of the Behavioral Health Person to Person Assault Procedure policy which included clarity on roles of the team for aggressor and assaulted persons, and decision making for team on behavioral management & safety of all patients. Hospitals MHUs - Safety & Security policy document review was completed, and changes included a Pathway which determines if immediate action is required, continually assess with care team, and if warranted, implement 5-minute safety round or inline of sight monitoring. Practice changes also included Vulnerable Adult (VA) & Child Maltreatment reports of abuse need to be filed immediately following the event or within 24 hours. Staff presence is required in the dining room when patients are present to observe, listen and monitor interactions. Staff to intervene and communicate to care team when boundary issues are present. Immediately following a patient-to-patient assault, nursing staff to consider location change, increased patient monitoring, close observation/sitter, or BICU placement If implementing 5-minute safety rounds - place a notify nursing order prior to initiating this increased level of observation.