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Based on record review, interview, policy review and surveillance video review, the facility failed to ensure patients were free from abuse. This affected one (Patient #4) of ten medical records reviewed. The census was 23.

See A115 and A145

Based on record review, interview, policy review and surveillance video review, the facility failed to ensure patients were free from abuse. This affected one (Patient #4) of ten medical records reviewed. The census was 23.

Findings include:

Patient #4 was admitted to the facility on 07/13/24 and discharged to an acute care hospital on 08/14/24.

The history and physical dated 07/13/24 stated the chief compliant was sexual behaviors and agitation. Patient #6 lived at home with her spouse but was currently on a respite stat at a nursing home. The nursing home reported Patient #4's baseline was pleasantly confused and cooperative with care. The patient has been displaying sexual behaviors and wandering over the last 72 hours per staff. On 7/10/24, the patient was in the dining room trying to feed other patients their breakfast. The patient was also getting into male patients faces and attempting to kiss them. On 07/12/24, the patient had spit out her medications and left them on the bedside table. The staff obtained a new order to crush all medications. The facility attempted to redirect but had no success. On 07/12/24, the patient got into the nurse's face and attempted to grab the nurse's breast. Patient has had zero previous psych stays.

Review of the nursing notes dated 08/14/24 at 8:00 AM documeted Patient #4 was asleep bed, no distress noted, refused breakfast. Vital signs stable. Safety maintained. At 10:30 AM, Patient #4 was sitting in milieu, groomed and dressed in gown. calm and pleasant mood. Safety maintained. At 12:30 PM, Patient #4 was sent to the emergency room via EMS (emergency medical services). Patient #4 was pushed down to the floor by Patient #6. Injury sustained to back of head. Patient stable, POA (Power of Attorney) notified. At 9:35 PM, Patient #4 was admitted to an acute care hospital's neuro trauma unit with a subarachnoid hemorrhage (brain bleed). Patient #4 did not return to the psychiatric hospital.

Patient #6 was admitted to the facility on 08/13/24 at 6:00 PM and discharged to an acute care hospital on 08/19/24.

The history and physical, dated 08/14/24, documented Patient #6 was admitted from a nursing home for behaviors and physical aggression. He had punched another resident at the nursing home multiple times in the face. He was sent to the emergency room for treatment of a urinary tract infection, then admitted to the psychiatric hospital.

Review of the nursing notes dated 08/14/24 at 8:00 AM revealed Patient #6 was asleep in his room. Awakens with ease. Patient #6 presents as irritable when asked if registered nurse could get his blood pressure. Patient replied "I don't have one. I don't want it. I'm leaving here!"

At 11:00 AM, Patient #6 allowed fellow registered nurse to take vital signs and was medication compliant. Presents as guarded and blunted. Patient ate of lunch. Patient refused care from RN (registered nurse) and NA (nursing assistant) and would not allow shower, catheter care, or skin check.

At 12:10 PM, Patient #6 attacked Patient #4 resulting in injury and attempted to hit another patient. Patient #6 was aggressive towards staff and peers, agitated and posturing towards staff.

At 12:31 PM, staff completed a physical hold in order to give PRN (as needed) medications. Patient received IM (intramuscular) Haldol 10 milligrams (mg ) and IM Benadryl 50 mg in the left deltoid. Patient #6 was escorted to his room and is now a one on one observation.

At 1:30 PM, the Patient #6 was asleep in bed. Breathing easy and unlabored. One on one staff present. IM medication was effective.

Nursing notes dated 08/16/24 at 9:00 AM documented the Patient #6 was calm, polite, compliant with care. The Patient #6 displayed poverty of speech. At 3:15 PM, Patient #6 was observed hitting another resident in chest and face and then attempting to kick other patient while the other patient was seated on the floor. Two staff were required to escort the Patient #6 to a safe place. Notified CNP (certified nurse practitioner). New order for one time dose of IM Haldol lactate 5 mg. Staff I further ordered Diphenhydramine 50 mg IM. Both IM medications were administered to patient with his consent, and well tolerated. Further order for patient to be one on one status.

At 4:30 PM, the Patient #6 remains on one to one observation. Calm, polite, displays poverty of speech.

Nursing notes dated 08/19/24 at 12:30 AM documented Patient #6 was resting in the bed with even and unlabored respiration No signs or symptoms of shortness of breath or respiratory distress noted, no complaints of pain or discomfort all safety measures in place. At 3:00 AM, the Patient #6 was laying in the bed and became verbally aggressive. Patient #6 got out of bed and walked to staff member and tried hit the staff member. The Patient #6 then walked to the Milieu verbally threating staff, chasing staff members trying hit them. He flipped two tables and a chair. Staff members unable to redirect or reorient. 911 was called and the Patient #6 was taken to an acute care hospital for evaluation. Patient #6 was discharged from the facility.

The facility's video surveillance recording of the incident dated 08/14/24 involving Patient #4 and #6 was reviewed. Patient #4 was wandering in the milieu when she walked up to Patient #6. Patient #6 puts his hands on Patient #4's shoulders and shoves her to the ground. She falls backward and hits her head on the floor. Staff immediately render aid to Patient #4 and escort Patient #6 from the area.

The agency's Root Cause Analysis (RCA) of the incident, dated 08/15/24, stated the incident occurred on 08/14/24 at 12:05 PM. Upon camera review and staff witness statements, on 08/14/24 at 12:05 PM, Patient #4 wandered into the personal space of her peer, Patient #6. As Patient #4 approached Patient #6, , he turned and pushed Patient #4 to the floor, causing Patient #4 to go backward and strike her head on the floor. Staff were present and separated Patient #6 from other patients immediately. Patient #4 sustained a laceration in her left occipital lobe. Staff applied pressure until EMS arrived. Patient #4 remained alert from the incident until EMS transported Patient #4 to the hospital. When staff called acute care hospital to check on the patient's status, it was noted that Patient #4 was admitted for a brain bleed.

Both the medical and psychiatric nurse practitioners responded to the event. Staff I, psychiatrist was notified. The aggressor received a PRN (as needed) emergency IM (intramuscular) injection to help calm behavior. Both responsible parties were advised of event.

The root cause was the Patient #6 impulsively pushed Patient #4 to the floor when Patient #4 entered Patient #6's personal space due to poor cognition.

The plan was Patient #6 was placed on one to one supervision until the psychiatrist determined one on one supervision was no longer required. Haldol 10 mg IM and Benadryl 50 mg IM were administered to the patient immediately. The patient was ordered Haldol 25 mg twice daily. Chart review and discussion regarding the process or administrative discharge occurred with Staff I.

During an interview on 08/28/24 at 9:24 AM. Staff A stated Patient #4 was pushed by the Patient #6. The Patient #6 had assaulted a patient in a nursing home. "He was impulsive. He would do nothing until he did something". Staff A stated Patient #4 had a small subdural bleed as a result of the incident and was admitted to acute care hospital. A second incident occurred when the Patient #6 struck Patient #8 in the face. Staff A reported the Patient #6 was administratively discharged because of his aggression. They called the acute care hospital and they agreed to take the Patient #6. "We felt we needed to protect our patients, we have very fragile patients".

During an interview on 08/29/24 at 9:05 AM, Staff A stated the Patient #6 was probably a patient who should have never came to this facility. "He definitely should not have been here". The facility normally only has one or two patient to patient assaults per month. The facility had four patient to patient incidents in February, two in June, one in July and six in August. Staff A reported the majority of the patients at this facility are here because they are "super aggressive" and have prior incidents. Staff A asked for the Patient #6 to be discharged on Friday, 08/16/24. During the weekend, the Patient #6 started pushing tables and became aggressive and they sent him out and would not accept him back. He was discharged 08/19/24. On the day of Patient #4's incident, staffing was three registered nurses, one licensed practical nurse, and 3.5 technicians. The facility also had a charge nurse and the Director of Nursing present.

The facility policy titled "Patient Rights and Responsibilities", issued May 2016, stated every person who enters Assurance Health for care has rights and responsibilities. He/she may exercise these rights while hospitalized. The hospital has the right to expect behavior on the part of patients and their relatives and friends, which considering the nature or their illness is reasonable and responsible. You have the right to be treated in a safe environment. with respect for personal dignity, autonomy and privacy in accordance with existing federal, state, and local laws and regulations. This includes the right to humane services, and the right to participate in any appropriate and available service that is consistent with your individual treatment plan, regardless of the refusal of any other service, unless that service is necessary for clear treatment reasons and requires your participation; reasonable protection from physical or emotional abuse or harassment.