HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to ensure that:
- The Chief Operating Officer (COO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- Staff appropriately followed Professional Assault Crisis Training (Pro-ACT, principles to reduce or eliminate the use of restraint, improve safety, and enhance treatment outcomes), which resulted in the physical injury of five current patients (#8, #10, #15, #16, and #31) of 29 current patients reviewed, and one discharged patient (#13) of six discharged patients reviewed. (A-0144)
- Vulnerable (in need of special care and protection) patients were protected from intentional harm to themselves and each other when one Psychiatric Technician (PT) who was monitoring a patient on line of sight (LOS, continuous visual contact with the patient) observation level was left alone in the gymnasium (gym) with five other patients, and one patient swallowed non-food items while on a one to one (1:1, continuous visual contact with close physical proximity) observation level. (A-0144)
- A safe environment was provided for patients and staff on inpatient units and in the gym, where new patients were taken to quarantine (a strict isolation imposed to prevent the spread of disease) upon arrival to the hospital when multiple ligature (anything which could be used for the purpose of hanging or strangulation) risks and mobile items were present that could be used to harm themselves and others. (A-0144)
- Techniques were used to provide appropriate de-escalation (reduce the intensity of a conflict or potentially violent situation). (A-0144)
- A complete and thorough investigation was completed following incidents where patients and staff had the potential to be or were injured by other patients, and recognized failures to prevent future re-occurrences. (A-0144)
- There was an effective, ongoing, hospital-wide, data driven Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program that worked in conjunction with the Governing Body and used data to monitor the quality, effectiveness and safety of care and services provided. (A-0283)
- All hospital departments were included in a hospital-wide QAPI program where data was used to identify opportunities for improvement, and actions were taken aimed at performance improvement, monitoring, and reporting, to provide patients with quality care and safety. (A-0283)
- Safe and adequate supervision of patients was maintained in the gymnasium (gym), when Staff K, Psychiatric Technician (PT), who was assigned to observe one patient (#21) on line of sight (LOS, continuous visual contact with the patient) observation level, was required to take on additional duties when Staff L Registered Nurse (RN) and Staff PP and KK, both PTs, exited the gym as Patient #12 escalated and assaulted Patient #8, leaving Staff K alone with one injured patient, one assaultive patient, and four additional patients. (A-0395)
- Patient #8 was protected from additional harm when the RN left the patient's immediate area and two security guards (Staff MM and NN) used improper holding techniques which allowed Patient #12 to re-assault Patient #8 and cause serious injury. (A-0395)
- Four patients (#21, #33, #34 and #35) of five remaining patients in the gym were properly monitored, assessed and protected when Patient #12 was not removed from the immediate area after he assaulted and injured a patient (#8). (A-0395)
- The Chief Nursing Executive (CNE) provided adequate supervision and evaluation of all nursing personnel. (A-0398)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body.

The hospital census was 65.

Based on interview, record review, and policy review, the Governing Body failed to ensure the Chief Operating Officer (COO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.12 Condition of Participation (COP): Governing Body, 482.13 COP: Patient's Rights, 482.21 COP: Quality Assessment and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) Program, and 482.22 COP: Nursing Services. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's undated document titled, "Governing Body Bylaws for Adult Psychiatric Facilities," showed that the Governing Body appoints one COO who is responsible for managing the entire hospital and keeping the Board apprised of all necessary information.

The COO failed to ensure compliance with the COP of Governing Body as evidenced by the ineffective mangement of the hospital that resulted in the failure to meet applicable regulatory requirements. (A-0057)

The COO failed to ensure compliance with the COP of Patient's Rights as evidenced by failure to ensure that:
- Staff appropriately followed Professional Assault Crisis Training (Pro-ACT, principles to reduce or eliminate the use of restraint, improve safety, and enhance treatment outcomes), which resulted in the physical injury of five current patients (#8, #10, #15, #16, and #31) of 29 current patients reviewed, and one discharged patient (#13) of six discharged patients reviewed. (A-0144)
- Vulnerable (in need of special care and protection) patients were protected from intentional harm to themselves and each other when one Psychiatric Technician (PT) who was monitoring a patient on line of sight (LOS, continuous visual contact with the patient) observation level was left alone in the gymnasium (gym) with five other patients, and one patient swallowed non-food items while on a one to one (1:1, continuous visual contact with close physical proximity) observation level. (A-0144)
- A safe environment was provided for patients and staff on inpatient units and in the gym, where new patients were taken to quarantine (a strict isolation imposed to prevent the spread of disease) upon arrival to the hospital when multiple ligature (anything which could be used for the purpose of hanging or strangulation) risks and mobile items were present that could be used to harm themselves and others. (A-0144)
- Techniques were used to provide appropriate de-escalation (reduce the intensity of a conflict or potentially violent situation). (A-0144)
- A complete and thorough investigation was completed following incidents where patients and staff had the potential to be or were injured by other patients, and recognized failures to prevent future re-occurrences. (A-0144)

The COO failed to ensure compliance with the COP of QAPI Program as evidenced by failure to ensure that there was an effective, ongoing, hospital-wide, data driven QAPI program that worked in conjunction with the Governing Body and used data to monitor the quality, effectiveness, and safety of care and services provided. The COO also failed to ensure that all hospital departments were included in a hospital-wide QAPI program where data was used to identify opportunities for improvement and actions were taken, aimed at performance improvement, monitoring, and reporting, to provide patients with quality care and safety. (A-0283)

The COO failed to ensure compliance with the COP of Nursing Services as evidenced by failure to ensure that:
- Safe and adequate supervision of patients was maintained in the gymnasium (gym), when Staff K, Psychiatric Technician (PT), who was assigned to observe one patient (#21) on line of sight (LOS, continuous visual contact with the patient) observation level, was required to take on additional duties when Staff L Registered Nurse (RN) and Staff PP and KK, both PTs, exited the gym as Patient #12 escalated and assaulted Patient #8, leaving Staff K alone with one injured patient, one assaultive patient, and four additional patients. (A-0395)
- Patient #8 was protected from additional harm when the RN left the patient's immediate area and two security guards (Staff MM and NN) used improper holding techniques which allowed Patient #12 to re-assault Patient #8 and cause serious injury. (A-0395)
- Four patients (#21, #33, #34 and #35) of five remaining patients in the gym were properly monitored, assessed and protected when Patient #12 was not removed from the immediate area after he assaulted and injured a patient (#8). (A-0395)
- The Chief Nursing Executive (CNE) provided adequate supervision and evaluation of all nursing personnel. (A-0398)

During an interview on 03/03/21 at 5:00 PM, Staff RR, Chief Operating Officer (COO), stated that she was responsible for the entire hospital and responsible for the oversight of the Governing Body, QAPI Program, Nursing Services and Patient's Rights.

Based on interview, record review, policy review, and review of video recording, the hospital failed to:
- Ensure staff appropriately followed Professional Assault Crisis Training (Pro-ACT, principles to reduce or eliminate the use of restraint, improve safety, and enhance treatment outcomes), which resulted in the physical injury of five current patients (#8, #10, #15, #16, and #31) of 29 current patients reviewed, and one discharged patient (#13) of six discharged patients reviewed.
- Protect vulnerable (in need of special care and protection) patients from intentional harm to themselves and each other when one Psychiatric Technician (PT), who was monitoring Patient #21 on line of sight (LOS, continuous visual contact with the patient) observation level, was left alone in the gymnasium (gym) with five other patients, resulting in Patient #12 physically assaulting Patient #8. Patient #17 physcially assaulted Patient #10 in the cafeteria, and patient #13 swallowed non-food items while on a one to one (1:1, continuous visual contact with close physical proximity) observation level.
- Provide a safe environment for patients and staff on inpatient units and in the gym when new patients were taken to quarantine (a strict isolation imposed to prevent the spread of disease) upon arrival to the hospital where multiple ligature (anything which could be used to attach a cord, rope or other material for the purpose of hanging or stranguation) risks and mobile items were present that could be used to harm themselves and others when Patient #9 verbally assaulted Patient #14, poured hot coffee on Staff C, PT, and Patient #31, struck Patient #31 with a large coffee container, threw items around in the breakfast area, kicked barricaded doors, then chased Patient #30 and #32 in an attempt to assault them, then assaulted Staff WW, RN, with a clock.
- Use techniques to provide appropriate de-escalation (reduce the intensity of a conflict or potentially violent situation).
- Complete a thorough investigation following incidents where patients and staff had the potential to be or were injured by other patients, and recognized failures to prevent future re-occurrences.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

The Severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). On 03/15/21, after the survey team informed the hospital of the IJ, staff created educational tools and began to educate all staff and put interventions into place to protect the patients.

As of 03/17/21, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Patients were no longer admitted to the gym.
- Office space (inpatient units where patients were quarantined which contained ligature risks) was no longer used to quarantine patients.
- A policy was developed that directed staff to notify the executive on call when an incident resulted in patient injury.
- Education was provided to staff that addressed observation levels, teamwork, de-escalation, securing the scene, and calling 911.

Based on interview, record review, policy review, and review of video recording, the hospital failed to:
- Ensure staff appropriately followed Professional Assault Crisis Training (Pro-ACT, principles to reduce or eliminate the use of restraint, improve safety, and enhance treatment outcomes), which resulted in the physical injury of five current patients (#8, #10, #15, #16, and #31) of 29 current patients reviewed, and one discharged patient (#13) of six discharged patients reviewed.
- Protect vulnerable (in need of special care and protection) patients from intentional harm to themselves and each other when one Psychiatric Technician (PT), who was monitoring Patient #21 on line of sight (LOS, continuous visual contact with the patient) observation level, was left alone in the gymnasium (gym) with five other patients, resulting in Patient #12 physically assaulting Patient #8. Patient #17 physcially assaulted Patient #10 in the cafeteria, and patient #13 swallowed non-food items while on a one to one (1:1, continuous visual contact with close physical proximity) observation level.
- Provide a safe environment for patients and staff on inpatient units and in the gym when new patients were taken to quarantine (a strict isolation imposed to prevent the spread of disease) upon arrival to the hospital where multiple ligature (anything which could be used to attach a cord, rope or other material for the purpose of hanging or stranguation) risks and mobile items were present that could be used to harm themselves and others when Patient #9 verbally assaulted Patient #14, poured hot coffee on Staff C, PT, and Patient #31, struck Patient #31 with a large coffee container, threw items around in the breakfast area, kicked barricaded doors, then chased Patient #30 and #32 in an attempt to assault them then assaulted Staff WW, RN, with a clock.
- Use techniques to provide appropriate de-escalation (reduce the intensity of a conflict or potentially violent situation).
- Complete a thorough investigation following incidents where patients and staff had the potential to be or were injured by other patients, and recognized failures to prevent future re-occurrences.

Findings included:

Review of the hospital's policy titled, "Adverse Events," dated 05/2019, showed:
- All adverse events as defined in this policy, shall have an incident report completed per hospital policy "Event Reporting," to initiate the review and documentation of due diligence in addressing the event.
- A timely, thorough, and credible Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) will be conducted and reported as required per this policy.
- The purpose of the policy was to provide a process for reviewing all adverse events that will ensure due diligence in review of adverse events. Will identify opportunities to reduce the risk of reoccurrence and focus the attention of the organization on understanding the causes that underlie the event and on changing processes and systems to reduce the probability of reoccurrence.
- Adverse events include those events identified by The Joint Commission as sentinel events. This includes major injury of another individual perpetrated by a patient.
- Following the occurrence of an adverse event, the facility will immediately provide prompt and proper medical and psychiatric care for any person affected by the adverse event.
- Following the occurrence of an adverse event, the facility will immediately contain the risk of reoccurrence.
- Following the occurrence of an adverse event, the facility the Chief Operating Officer (COO) may initiate a formal RCA and assign a RCA Team Leader and team members that shall consist of administrative staff and individuals directly identified as part of the event.
- If an RCA is initiated, the team will meet as soon as possible after the event to gather information about the event while the event is still fresh in the memory of those involved.
- The entire RCA process of review must be completed within 45 days.
- Adverse events and actions plans were reported to the Governing Body by the COO, Medical Director or the Quality Improvement Director at quarterly meetings of the Governing Body.

Review of the hospital's policy titled, "Event Reporting," dated 05/2019, showed the following:
- The hospital would document all unusual incidents, accidents, or injuries as established by the Department of Mental Health (DMH).
- The purpose of the policy was to prescribe procedures for reporting and recording critical incidents and other incidents.
- An event was defined as the unusual occurrence or event that led to an undesirable outcome which included but was not limited to physical altercation or injury.
- A critical event was defined as a significant incident involving department services, facilities, or patients that would be reported to key department administration.
- An event report would be completed during the shift in which the event occurred or was discovered by the person who observed or discovered the event.
- The completed and reviewed incident would be submitted to the department head or nurse manager who would check the form for completeness and accuracy. The department head or nurse manager would present the incident report in the next Incident Analysis (IA) meeting.
- The IA group would review the event unit, date, time, incident type, and description of each incident report completed since the previous IA meeting.
- The "Decision" section would be completed during the IA meeting at the direction of the COO.
- If the event was critical, as defined by DMH directive, the incident report would be reported to the COO's office as soon as possible following the occurrence of the event. The COO would determine the criticality of the incident and, if additional follow-up would be needed, the COO would direct the staff to complete the follow-up and report on findings within a specific period.

Review of the hospital's undated document titled, "Pro-ACT Participant Manual," showed the following:
- Pro-ACT emphasized team skills, not individual skills, and mirrored a teamwork experience.
- Always check with others before leaving an area, do not abandon team members.
- A lack of teamwork contributed to injuries.
- Failing to respond to and assist with assaultive incidents contributed to avoidable injuries to others.
- Managers were to provide employees with adequate supervision, security and training to avoid injuries to others.
- Potentially dangerous behaviors prior to a crisis included a change in appearance, change in demeanor or condition, and a change in activity level.
- Interventions used to avoid a crisis situation included addressing the client's needs (ask if they were tired, hungry, felt unsafe, thirsty, lonely, felt poorly or were in pain), reduce demands, and increase support by sitting together, taking a walk, having a conversation or offering reasonable choices to the patient.
- Determining baseline behaviors for each patient that staff were responsible for helped to assess possible indicators of impending dangers with patients.
- It was very important to be aware of the environment and take particular note of items easily used as weapons or items that could obstruct mobility.
- Employees who identified triggers, understood their own role in reducing the risk of escalation (an increase in the intensity or seriousness of conflict or potentially violent situation), and responded with safe alternatives during the escalation phase were better able to interrupt the cycle of assault and reduce the risks presented by crisis behavior.
- Debriefing was a key element in crisis prevention and included staff and patient perspectives.
- An assault crisis identified a treatment failure and debriefing was designed to evaluate the crisis and analyze why the plans did not work.
- Debriefing included staff and patients and should be supportive, constructive and focused on prevention of future crises.

Review of the hospital's document titled, "Pro ACT Aggression Management Training," dated 03/2016, showed the following:
- Prevention and management of aggressive and violent behavior was an essential skill for all staff.
- All staff were trained on an annual basis to provide patient care with a humane and respectful approach in a therapeutic environment.
- Physicians and Resident Physicians, Mental Health Managers, Nursing staff, Social Work staff, Rehabilitation staff, Psychologists, Security Officers, Clinical Pharmacists, Environment Services and Clinical Dietitians must recertify annually to maintain competency in Pro ACT.
- New employees must complete required Pro ACT training within three months of their employment.
- Supervisors and managers of patient care areas must assure that a sufficient number of certified staff were available.

Review of the hospital's policy titled, "Safety, Nursing's Responsibility," dated 07/2020, showed the following:
- The Nurse Manager and nurse in charge assumed ultimate responsibility for assuring the safety of the patients, visitors, staff and the environment.
- All nursing staff shall be responsible for taking immediate action by implementing the appropriate intervention in all conditions that jeopardized the safety of others and the environment.
- In the event of an unsafe condition, the charge nurse would take immediate action to restore a safe environment.
- The nurse in charge was responsible for an ongoing environmental surveillance and to take appropriate action to correct the dangerous conditions, hazardous practices or safety-related concerns.

Review of the hospital's document titled, "Restraint/Seclusion - Use Of," dated 06/2018, showed that safe and appropriate restraint/seclusion techniques were utilized to prevent physical harm to oneself and others. Constant supervision was defined as one staff member who was specially assigned to appropriately monitor, and visually monitor patients on constant observation and care for the patient's needs, which included providing a safe environment for the patient during an event.

Review of the hospital's document titled, "Observation Levels," dated 06/2018, showed the following:
- Close observation/line of sight meant that assigned staff members must have the patient in their sight at all times to provide support and intervene as needed.
- Patients on a 1:1 or 2:1 must have staff within 10 feet of the patient at all times to provide support and to intervene as needed.
- 1:1 and 2:1 were used when a patient verbalized a clear intent to harm themselves or others, had a concrete plan or exhibited unsafe behaviors.
- Upon admission and as necessary during the course of treatment, staff must evaluate the need for the development of treatment interventions for identified risks in areas including assault, suicide, elopement, seizures, choking, falls and sexual risks.
- All staff were authorized to implement interventions that develop as a response to risk factors.
- At any time during the patient's course of treatment, staff may develop a treatment plan or request the physician to order a special observation level based on identified risks the patient clinically presented.

Review of the hospital's document titled, "Assistance Required," dated 04/2019, showed the following:
- All available staff were expected to respond when requested via overhead page stating "Assistance Required."
- An assistance required was called by a staff member when more staff were required to handle a potentially dangerous situation.
- When a patient lost control, no matter what the cause, the goal was to assist the patient to de-escalate without causing further psychological or physical harm to themselves, other patients or staff.
- An assistance required should be called when a patient was threatening immediate physical or psychological danger to themselves or others, and more assistance was required to intervene with the crisis.
- An assistance required should have a designated event manager whose responsibility was to deploy unit staff and responding staff during a disruptive event.
- The event manager would be the physician or resident on call but could be any staff discipine from the unit who took the event manager role in case the physician or resident on call had not arrived to the unit or was directly needed in the de-escalation of disruptive behavior.
- Each shift the nurse in charge would function as the backup event manager to ensure the duties were carried out in case the physician or resident on call was otherwise occupied.
- The event manager would assure necessary ongoing activities were maintained on the unit while the team captain and assigned responders de-escalated the event.
- Each work area would send trained employees as they were available.
- Staff that responded to the location should allow themselves to be directed by the event manager.
- Staff would not leave the area without permission of the event manager.
- The event manager would assign responding staff to patient care tasks, such as escorting other patients out of the immediate area for the purpose of preserving the safety and dignity of everyone involved.
- Unit staff may request Security to respond, or to stand by on a unit, if a patient was agitated or an incident was anticipated due to an adverse situation. The intent would not be for hands-on assistance, but for additional staff support on the unit. Security would only provide hands-on assistance if directed by the event manager.

Review of Patient #8's medical record from Hospital A dated 03/02/21 through 03/08/21, showed the following:
- He was a 53-year-old male.
- He was admitted on 03/02/21, from a county jail, per court order.
- His admission diagnosis included schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), developmental disability (a group of conditions due to an impairment in physical, learning, language, or behavior), cannabis use disorder (the continued use of the psychoactive drug from the cannabis plant despite clinically significant impairment), and methamphetamine use disorder (continued abuse of methamphetamine; a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant).
- He had notable previous head injuries that included being struck with a hammer in 1974 and a physical assault at a county jail in 2014, which resulted in serious head and facial trauma.
- Upon admission, he was placed in the open gym on 15-minute observations.
- On 03/07/21, nursing documentation showed that he was taken to the Emergency Department (ED) after being repeatedly punched and kicked by another male patient in the gym. The patient's eyes were swollen and he was bleeding from the nose and mouth. He did not lose consciousness, but he was confused as to what happened.
- On 03/08/21, physician documentation showed that he was admitted to Hospital B for fractures (a break in a bone) to the right eye socket, fractures of the maxillary (bone in the cheek area next to the nose) sinuses (a cavity in the bone of the skull that interconnects with the nostrils and contains air), a fracture to the right pterygoid plate (a thin plate of bone, on both sides of the sinuses, which join together and hold the muscles for chewing), and fractures to the nasal bones and septum (cartilage in the nose that separates the nostrils). No surgery was performed.

Review of Patient #8's medical record from Hospital B dated 03/07/21, showed the following:
- He presented to the ED on 03/07/21 at 6:19 PM.
- A computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan of the face was performed.
- It showed extensive facial bone fractures to the walls of the right eye socket as well as every wall of both maxillary sinuses.
- Right pterygoid plate fractures.
- A fracture of the nasal septum and fractures of the nasal bones.
- A right jawbone fracture.
- Extensive facial bone hematomas (collection of blood below the surface of the skin) and excessive bleeding in both sinuses.
- He received multiple sutures (medical device used to hold skin together after an injury or surgery) to his face.
- He was admitted for evaluation and intravenous (IV, in the vein) antibiotics (medications that destroy or slow down the growth of bacteria).
- He was discharged back to Hospital A on 03/09/21.

Review of Patient #12's medical record dated 03/03/21 through 03/09/21, showed the following:
- He was a 28-year-old male.
- He was admitted on 03/03/21, from a county jail, per court order.
- His admission diagnosis included schizophrenia and substance use disorder.
- His admission suicide risk assessment showed "high impulsivity with agitation."
- His admission intake noted that he frequently experienced auditory hallucinations (hearing things that weren't there) and responded to internal stimuli (something which causes an action or response).
- He had a history of violence toward others.
- On 08/09/20, while in jail, he physically assaulted his cell mate, which required emergency treatment for his injuries.
- Upon admission, he was placed in the open gym on 15-minute observations.
- On 03/05/21 at 8:26 AM, the unit nurse was notified that he had increased pacing, yelling out and agitation. Morning medications were offered and the patient refused. The resident on call was notified and no other interventions were listed.
- On 03/06/21 at 10:05 AM, nursing documentation noted his behaviors were delusional, anxious, and rambling. He had experienced hallucinations, he was oppositional, and he was not participating in treatment.
- On 03/06/21 at 3:09 PM, nursing documentation noted the nurse was notified of an event at 2:55 PM, where he had "increased anxiety and was demonstrating aggressive behavior from internal stimuli toward other clients and staff." The medication nurse, resident on call, and Security were notified. At 3:05 PM, the patient refused medication and he also refused morning medication as ordered. No other interventions were documented.
- On 03/07/21, the daily nursing progress note had no behaviors documented.
- On 03/07/21 at 6:37 PM, nursing documentation noted that the patient violently assaulted another male peer unprovoked. He came up behind him and punched him and kicked him repeatedly, and kicked him in the stomach and back. The male peer was seriously injured and bleeding from his nose, mouth, and his eyes were swollen. The patient said that the male peer was bothering him. He was making very rapid nonsensical statements and the patient needed to be restrained with board and body net restraints.
- On 03/09/21 at 7:04 AM, physician documentation noted that based on the recent extremely violent aggression toward another peer on the unit, the patient would be transferred to a higher security hospital on the morning of 03/10/21.

Review of two hospital video recordings titled, "Gym Cam1 and Gym Cam2," dated 03/07/21, showed two views of the gym. The review showed the following:
- 5:30:51 PM, Staff L, Registered Nurse (RN); Staff K, PT; and Staff PP, PT, were visualized at a table near the gym entrance. Staff KK, PT, was seated in the middle of the gym at a table against the wall.
- 5:30:55 PM, Patient #12 was seated in a chair at the far end of the gym. He appeared to be gesturing with his hands, speaking, and looking toward the area where staff were seated. Patient #8 was visualized pacing at the end of the gym.
- 5:31:10 PM, Staff PP exited the gym.
- 5:31:20 PM, Patient #8 began pacing around the middle of the gym.
- 5:31:44 PM, Patient #12 pushed the tray table on the side of his chair down and continued to gesture with his hands and talk in the direction of staff.
- 5:33:30 PM, Staff KK exited the gym.
- 5:33:30 PM, Patient #8 continued to pace the gym.
- 5:34:07 PM, Patient #8 walked to the center of the gym and began to re-arrange a set of tables and chairs. Patient #12 still seated in the chair, continued to gesture and talk in the direction of staff.
- 5:35:01 PM, Patient #12 stood up from the chair and turned toward the area where staff were seated. He continued to gesture and appeared to be talking. He stomped his foot on the floor.
- 5:35:17 PM, Patient #12 walked toward the center of the gym and his behaviors continued.
- 5:35:48 PM, As Patient #12's behavior continued, Staff L, RN, exited the gym. Staff K, PT, remained seated at the table.
- 5:35:56 PM, Patient #12 began to walk alongside Patient #8.
- 5:36:18 PM, Patient #8 continued to move objects in the middle of the gym. Patient #12's behaviors continued.
- 5:36:25 PM, Patient #12 walked up to Patient #8 and struck him in the face with a closed fist. Patient #8 fell to the ground.
- 5:36:27 PM, Staff K stood up from the table and ran to the middle of the gym toward the patients.
- 5:36:30 PM, Patient #12 walked around Patient #8, who was lying on the floor, and began to stomp on his head.
- 5:36:33 PM, Staff L, RN, opened the gym door but did not enter. Staff NN, Security Officer, entered the gym. Patient #12 continued to stomp on Patient #8's head.
- 5:36:38 PM, Staff K, PT, pulled Patient #12 by the arm away from Patient #8.
- 5:36:40 PM, Staff K released Patient #12's arm as Staff NN, Security Officer, approached the area.
- 5:36:46 PM, Staff L, RN, and Staff PP, PT, re-entered the gym.
- 5:36:56 PM, Patient #12 began pacing and shoved a chair into a table. Staff NN and Staff K did not intervene with Patient #12.
- 5:36:56 PM, Patient #12 turned, walked toward the television and chair, turned around, and began walking back toward the middle of the gym.
- 5:36:59 PM, Staff L, RN, approached Patient #8 on the ground.
- 5:37:17 PM, Staff MM, Security Officer, entered the gym.
- 5:37:20 PM, as Staff L, RN, saw Patient #12 re-approach the area, she stood up and walked away from Patient #8 while he was still lying on the ground.
- 5:37:25 PM, Staff NN, Security Officer, was positioned on the right side of the Patient #8 and Staff MM, Security Officer, was positioned approximately four feet behind Staff NN. Staff K, PT, was positioned to the right of Patient #8's head.
- 5:37:29 PM, Patient #12 approached Patient #8 from the left side and shoved a table out the way. As Staff K, PT, took a step forward, and Staff NN stepped over Patient #8's body, Patient #12 stomped on Patient #8's head another time.
- 5:37:31 PM, Staff K, Staff NN and Staff MM lunged toward Patient #12, placed him in a manual hold, and put him on the ground.
- 5:37:34 PM, Staff L, RN, ran toward the gym door where she remained before returning to assess Patient #8 at 5:38:05 PM. Patient #12 remained restrained on the gym floor.
- 5:38:29 PM, Additional staff began to respond to the gym.
- 6:02:10 PM, EMS arrive in the gym to transport Patient #8 to the hospital.

Review of the hospital's document titled, "Single Event," completed by Staff L, RN, dated 03/07/21, showed that:
- She was in the gym when Patient #12's behavior escalated.
- She felt that Patient #12 began to focus on her so she exited the gym door and watched through the door window.
- Patient #12's focus shifted to Patient #8.
- Patient #12 walked toward Patient #8 and he began hitting him with a closed fist and Patient #8 fell to the ground.
- At that time, she re-entered the gym and yelled, "Stop!" three or four times.
- Another staff member went to block Patient #12.
- Patient #12 began to stomp and kick Patient #8 in the head, back, and stomach.
- Patient #8 was going in and out of consciousness and a large amount of blood was running out of his head, nose and mouth.
- Patient #12 had been placed in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others).
- She directed staff to place Patient #12 in a net restraint (vinyl net that is used to wrap a patient securely) for his safety.

During an interview on 03/10/21 at 3:40 PM, Staff K, PT, stated the following:
- Six new patients were admitted into the gym on the same day so that they could quarantine for 14 days prior to being placed on the units.
- A 1:1 was required for patients that were in danger of harming themselves or others, psychotic patients, and patients who refused their medications.
- During the incident on 03/07/21, there were three PTs assigned to the gym, and he was on a 1:1 with Patient #21.
- No one in administration had talked with him following the incident on 03/07/21.
- There were no changes made in the gym, or education to staff following the incident on 03/07/21.
- There had been no education following any incidents involving injuries at the hospital that he could remember.
- When a code assist was called, any available staff were to respond. Sometimes the women responded, but usually it was the men on the units that went.

During an interview on 03/10/21 at 4:00 PM, Staff L, RN, stated the following:
- The gym was being used as a transitional unit for new patients who could have COVID-19 (highly contagious, and sometimes fatal, virus) before they were placed onto the other units.
- On 03/07/21, she was not assigned to the gym, and she just went down to the gym to see what one of her patients she was going to give medications to looked like.
- The tables and chairs in the gym were not safe for psychiatric patients.
- She tried to care for Patient #8 after he was attacked, she placed him on his left side and he was going in and out of consciousness, but no one was doing anything to help her.
- She felt that it was taking a long time for the ambulance to come, then realized after 30 minutes that no one had called 911.
- She felt that the gym was unsafe and there could easily be another incident like the one on 03/07/21.
- She felt that nursing assessments weren't thorough enough for the new patients.
- There was no investigation that she knew of following the incident on 03/07/21, and no one had spoken with her about it.
- There was no education provided to staff following the incident on 03/07/21.

During an interview on 03/11/21 at 3:25 PM, Staff N, Chief Nursing Executive (CNE), stated that he did not watch the incident that happened in the gym on 03/07/21, until that day because, "it's really hard to watch the videos." As long as there were vacant beds, the gym would be utilized to house new patients prior to being placed on the units. The gym was not psychiatric safe. He was part of a risk assessment team that decided to use the gym for admissions, and it may not be ideal, but they had to keep admissions flowing. The nurses did have oversight of the units and provided medications to patients in the gym, but the direct supervision in the gym was performed by the PTs. Security officers were placed outside of the gym so that they would reduce the patient exposure to Covid-19. A PT who was doing a 1:1 with a patient should have no other duties while they were providing 1:1 observation.

Review of Patient #17's medical record showed that he was a 37-year-old male admitted on 04/12/19, with a past medical history of major depressive disorder (long period of extreme sadness that doesn't go away), severe psychotic features (characterized by false ideas about what is taking place or who one is), generalized anxiety disorder (chronic condition where fear and worry impairs a person's ability to function and interferes with their well-being), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), intermittent explosive disorder (repeat sudden episodes of impulsive aggressive, violent behavior or angry verbal outbursts in that are grossly out of proportion to the situation), substance abuse, and antisocial personality disorder (a type of mental disorder in which a person has a rigid and unhealthy pattern of thinking, functioning and behaving). He was admitted to the hospital from jail, where he assaulted his cell mate and often showed defiant behavior (often losing your temper, combative, cranky and argumentative) to the prison officers and made statements that he planned to harm himself. He admitted to staff that he assaulted Patient #10 because he looked at him wrong.

Review of the hospital's document titled, "Single Event," dated 01/26/21, showed that Patient #17 was in the kitchen area and assaulted Patient #10 from behind when he pushed, shoved and tripped him. Patient #10 was on the floor and Patient #17 kicked him multiple times in the head and upper body. Patient #10 was bleeding from the nose and mouth, had an abrasion on his forehead, a cut on his upper lip and one loose tooth. The two patients were separated and Patient # 17 received a medication for agitation and was placed on line of sight observation. Patient #10 was sent to the ED for evaluation and treatment of his injuries. There was no documentation that the event was ever discussed with staff.

Review of Patient #13's medical record showed that she was a 29-year-old female with an extensive past psychiatric history of depression, anxiety, Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock), and intellectual disability, who was admitted to the hospital on 10/14/20. Six months prior to her admission, she had multiple episodes of banging her head against a wall, scratching her arms, and she ingested batteries and razors while she was in jail. She was on a 1:1 observation on both 01/11/21 and 01/13/21, when she swallowed part of her comb and batteries.

Review of the hospital's document titled, "Single Event," dated 01/11/21, showed that Patient #13 told staff that she had swallowed the tines from her hair pick. She was sent to the ED for evaluation and treatment. There was no documentation that the event was discussed with staff.

Review of the hospital's document titled, "Single Event," dated 01/13/21, showed that Patient #13 swallowed batteries from a remote control after banging on it to get it open while she was on a 1:1 observation because of self-harm. The staff member in charge of the 1:1 admitted that she was distracted by watching television and did not provide appropriate supervision to Patient #13 which resulted in serious physical injury. The patient required an esophagogastroduodenoscopy (EGD, procedure in which a thin scope with a light and camera at its tip is used to look inside the organs of the upper digestive tract) where they removed two batteries and part of a comb. The staff providing the 1:1 with Patient #13 was placed on leave following the incident. There was no documentation that the event was discussed with staff.

Review of Patient #9's medical record showed that he was a 28-year-old male with a psychiatric history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) admitted from jail on 01/13/21. While he was in jail, he was agitated, saw and heard things that were not there, had disorganized thoughts, smeared his feces, slept for only a few hours at a time, and often times he did not know who he was, where he was, or what period of time it was. He had assaulted a social worker during a previous hospital stay. Patient #9 was a line of sight observation level during the events on 01/18/21, 01/20/21 and 01/26/21. He was on a 2:1 observation level on 02/02/21 and 02/19/21.

Review of the hospital's document titled, "Single Event," dated 01/18/21, showed that Patient #9 threw items at Patient #16 and pulled him out of his bed in the gym. Patient #9 then received an medication injection to help him calm down. Documentation showed that Patient #16 was separated from Patient #9 following a prior incident. Patient #16 was eventually moved to another unit out of the gym to keep him safe from Patient #9. Staff added interventions for aggression and increasing frustration tolerance to Patient #9's treatment plan and he remained on line of site observation level.

Review of the hospital's document titled, "Single Event," dated 01/20/21, showed that Patient #9 removed two metal legs from a cot in the gym and gave them to Staff C, PT. Documentation showed that administration was told about the metal cot legs in a meetin

Based on interview, record review and policy review, the hospital failed to integrate event reports (documented incidents that allow the risk management team to consider changes that might prevent similar incidents) as part of the hospital's Quality Assessment and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program, to ensure the hospital assessed, identified, and implemented actions to improve performance. These failures had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.21 Condition of Participation: QAPI Program and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 65.

Based on interview, record review and policy review, the hospital failed to integrate event reports (documented incidents that allow the risk management team to consider changes that might prevent similar incidents) as part of the hospital's Quality Assessment and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program, to ensure the hospital assessed, identified, and implemented actions to improve performance. These failures had the potential to put all patients at risk for sub-standard quality of health care and adverse outcomes.

Findings included:

Review of the hospital's policy titled, "Event Reporting," dated 05/2019, directed staff to forward completed event reports to the Chief Operating Officer (COO), who would then send them to the Quality Management staff, who logged, and filed the event reports.

Review of the hospital's document titled, "Performance Improvement Plan," dated 10/27/20, showed that the QAPI Committee was responsible to design, measure, assess and improve its performance through identifying those issues that were high volume, high risk and/or problem prone.

During an interview on 03/17/21 at 12:02 PM, Staff RR, COO, stated that event reports were not reviewed as part of QAPI, and no trending of data was performed for event reports.

During an interview on 03/17/21 at 10:37 AM, Staff N, Chief Nursing Executive (CNE), stated that he did not receive or review event reports, and event reports were not reported as part of the QAPI meetings.

During an interview on 03/12/21 at 9:35 AM, Staff J, Quality Analyst Specialist, stated that event reports were not sent to the QAPI Committee.

During an interview on 03/17/21 at 12:31 PM, Staff O, Medical Director, stated that event reports were not reviewed as part of QAPI.

Review of the QAPI Committee minutes from 10/27/20 and 12/17/20, showed no review, data analysis or performance improvement actions, as related to event reports.

During an interview on 03/15/21 at 11:35 AM, Staff C, Psychiatric Technician, stated that he did not know about QAPI projects (monitored interventions to improve performance and prevent negative patient events).

Based on observation, interview, record review, policy review and video review, the hospital failed to ensure that:
- Safe and adequate supervision of patients was maintained in the gymnasium (gym), when Staff K, Psychiatric Technician (PT), who was assigned to observe one patient (#21) on line of sight (LOS, continuous visual contact with the patient) observation level, was required to take on additional duties when Staff L Registered Nurse (RN) and Staff PP and KK, both PTs, exited the gym as Patient #12 escalated and assaulted Patient #8, leaving Staff K alone with one injured patient, one assaultive patient, and four additional patients.
- Patient #8 was protected from additional harm when the RN left the patient's immediate area and two security guards (Staff MM and NN) used improper holding techniques which allowed Patient #12 to re-assault Patient #8 and cause serious injury.
- Four patients (#21, #33, #34 and #35) of five remaining patients in the gym were properly monitored, assessed and protected when Patient #12 was not removed from the immediate area after he assaulted and injured a patient (#8).
- The Chief Nursing Executive (CNE) provided adequate supervision and evaluation of all nursing personnel.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

The hospital census was 65.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 03/15/21, after the survey team informed the hospital of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients. As of 03/17/21, at the time of the survey exit, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Patients were no longer admitted to the gymnasium.
- Office space (areas where ligature risks were found) was no longer being used to quarantine (a strict isolation imposed to prevent the spread of disease) patients.
- A policy was developed that directed staff to notify the executive on call when an incident resulted in patient injury.
- Education was provided to staff that addressed observation levels, teamwork, de-escalation, securing the scene, and calling 911.

Based on observation, interview, record review, policy review and video review, the hospital failed to ensure that:
- Safe and adequate supervision of patients was maintained in the gymnasium (gym), when Staff K, Psychiatric Technician (PT), who was assigned to observe one patient (#21) on line of sight (LOS, continuous visual contact with the patient) observation level, was required to take on additional duties when Staff L Registered Nurse (RN) and Staff PP and KK, both PTs, exited the gym as Patient #12 escalated and assaulted Patient #8, leaving Staff K alone with one injured patient, one assaultive patient, and four additional patients.
- Patient #8 was protected from additional harm when the RN left the patient's immediate area and two security guards (Staff MM and NN) used improper holding techniques which allowed Patient #12 to re-assault Patient #8 and cause serious injury.
- Four patients (#21, #33, #34 and #35) of five remaining patients in the gym were properly monitored, assessed and protected when Patient #12 was not removed from the immediate area after he assaulted and injured a patient (#8).

These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

1. Review of the hospital's policy titled, "Observation Levels," dated 06/2018, showed that:
- Close observation/line of sight meant that assigned staff members must have the patient in sight at all times to provide support and intervene as needed.
- Toileting and bathing for patients on close observation/line of sight will occur with the patient in continuous visual observation at all times.
- Close observation/line of sight observation was generally used for patients that are having difficulty managing their behaviors and have verbalized clinical risk toward self or others.
- Patients on a 1:1 or 2:1 must have staff within 10 feet of the patient at all times to provide support and to intervene as needed.
- 1:1 and 2:1 were used when a patient verbalized a clear intent to harm themselves or others, had a concrete plan or exhibited unsafe behaviors.
- Upon admission and as necessary during the course of treatment, staff must evaluate the need for the development of treatment interventions for identified risks, including assault., suicide (to cause one's own death), elopement (when a patient makes an intentional, unauthorized departure from a medical facility), seizures (excessive activity in the brain which causes uncontrolled jerking movements), choking, falls and sexual risks.
- All staff were authorized to implement interventions that develop as a response to risk factors.
- At any time during the patient's course of treatment, staff may develop a treatment plan or request the physician to order a special observation level based on identified risks the patient clinically presents.

Review of the hospital's policy titled, "Observation Levels and Safety Management," dated 05/2020, showed that the nurse in charge is ultimately responsible in directing the safety and care of the patient. All nursing staff are responsible for carrying out their assigned duties under the direction and supervision of the nurse in charge.

Review of the hospital's policy titled, "Safety, Nursing's Responsibility," dated 07/2020, showed that:
- The Nurse Manager and nurse in charge assumes ultimate responsibility for assuring the safety of the patients, visitors, staff and the environment.
- All nursing staff shall be responsible for taking immediate action by implementing the appropriate intervention in all conditions that jeopardize the safety of others and the environment.
- In the event of an unsafe condition, the charge nurse takes immediate action to restore a safe environment.
- The nurse in charge is responsible for an ongoing environmental surveillance and takes appropriate action to correct the dangerous conditions, hazardous practices or safety-related concerns.

Review of the hospital's policy titled, "Nursing Scope of Service and Staffing Plan," dated 07/2020, showed that minimum RN coverage is one RN per unit.

Review of the hospital's document titled, "Assistance Required," dated 04/2019, stated the following:
- All available staff were expected to respond when requested via overhead page stating "Assistance Required."
- When a patient lost control, no matter what the cause, the goal was to assist the patient to de-escalate without causing further psychological or physical harm to themselves, other patients or staff.
- An assistance required should be called when a patient was threatening immediate physical or psychological danger to themselves or others, and more assistance was required to intervene with the crisis.
- An assistance required should have a designated event manager whose responsibility was to deploy unit staff and responding staff during a disruptive event.
- Staff who responded to the location should allow themselves to be directed by the event manager.
- Staff would not leave the area without permission of the event manager.
- The event manager would assign responding staff to patient care tasks, such as escorting other patients out of the immediate area for the purpose of preserving the safety and dignity of everyone involved.

Review of the hospital's undated document titled, "Professional Assault Crisis Training (Pro-ACT, principles to reduce or eliminate the use of restraint and improve safety and enhance treatment outcomes) Participant Manual," showed that:
- Pro-ACT emphasized team skills, not individual skills, and mirrored a teamwork experience.
- Always check with others before leaving an area, do not abandon team members. A lack of teamwork contributed to injuries.
- Failing to respond to, and assist with assaultive incidents, contributed to avoidable injuries to others.
- Managers were to provide employees with adequate supervision, security and training to avoid injuries to others.
- Potentially dangerous behaviors prior to a crisis included a change in appearance, change in demeanor or condition, and a change in activity level.
- Interventions used to avoid a crisis situation included addressing the client's needs (ask if they were tired, hungry, felt unsafe, thirsty, lonely, felt poorly or were in pain), reduce demands, and increase support by sitting together, taking a walk, having a conversation or offering reasonable choices to the patient.
- Determining baseline behaviors for each patient that staff were responsible for, helped to assess possible indicators of impending dangers with patients.
- It was very important to be aware of the environment, and take particular note of items easily used as weapons or which could be obstructions to mobility.
- Employees who identified triggers, understood their own role in reducing the risk of escalation, and responded with safe alternatives during the escalation phase, were better able to interrupt the cycle of assault and reduce the risks presented by crisis behavior.

Review of the hospital's document titled, "Pro ACT Aggression Management Training," dated 03/2016 showed that prevention and management of aggressive and violent behavior was an essential skill for all staff. All staff were trained on an annual basis to provide patient care with a humane and respectful approach in a therapeutic environment.

Review of the hospital's policy titled, "Adverse Events," dated 05/2019, showed that following the occurrence of an adverse event, the hospital will immediately provide prompt and proper medical and psychiatric care for any person affected by the adverse event and immediately contain the risk of reoccurrence.

Review of the hospital's document titled, "Understanding Mental Illness," dated 03/2011, showed that when a person with a serious, chronic mental disorder becomes violent, direct others to leave the area slowly and quietly. Be sure that other people are out of potential danger.

Review of Patient #21's medical record showed the following:
- He was a 21-year-old male admitted to the hospital's Gymnasium Unit on 03/01/21 with a court order for competency restoration (the process by which a judge determines if an individual with a mental illness or intellectual disability is found to be able to make his/her own decisions).
- Upon admission he was placed in the open gym on 15-minute observations.
- He had the current charges of possession of a controlled substance (drugs or medications that are high risk for personal consumption or abuse), property damage and harassment (aggressive pressure or intimidation).
- While in jail, the patient had self-harming behaviors, such as hitting his head against a wall and engaged in inappropriate elimination, such as urinating and defecating (to discharge feces from the body) in his cell and holding his feces (waste matter discharged from the bowels after food has been digested) in his hands.
- His psychiatric assessment diagnosis on admission was unspecified schizophrenia spectrum (USS, diagnosis assigned to individuals who are experiencing symptoms of schizophrenia [serious mental disorder that affects a person's ability to think, feel, and behave clearly], but do not meet the full criteria) and other psychotic disorder (OPD, a mental diagnosis assigned when an individual loses contact with reality and experiences false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature).
- On 03/03/21 at 3:00 PM, the patient was placed on 1:1 observation and then line of sight observation (lower observation level than 1:1) for self-harm behavior (rubbing his bed sheet until his right hand started bleeding), overtly psychotic and confused behavior.
- On 03/03/21 at 5:38 PM, the patient was visibly agitated and aggressive toward staff and peers.

During an interview on 03/10/21 at 3:40 PM, Staff K, PT, stated that on 03/07/21, he was assigned and responsible for the observation of Patient #21 in the gym.

Review of Patient #12's medical record showed the following:
- He was a 28-year-old male admitted to the hospital's Gymnasium Unit on 03/03/21 with a court order for competency restoration.
- His admission diagnosis included schizophrenia and substance use disorder.
- His admission suicide risk assessment showed "high impulsivity with agitation."
- His admission intake noted that he frequently experienced auditory hallucinations (hearing things that are not heard by others, imaginary) and responded to internal stimuli (something which causes an action or response).
- He had a history of violence toward others.
- On 08/09/20, while in jail, he physically assaulted his cell mate, which required emergency treatment for his injuries.
- Upon admission he was placed in the open gym on 15-minute observations.
- On 03/05/21 at 8:26 AM, the unit nurse was notified that he had increased pacing, yelling out and agitation. Morning medications were offered and the patient refused. The resident on call (ROC) was notified, but no other interventions were documented.
- On 03/06/21 at 10:05 AM, nursing documentation noted his behaviors as delusional (false ideas about what is taking place or who one is), anxious, and rambling. He had experienced hallucinations, he was oppositional, and he was not participating in treatment.
- On 03/06/21 at 3:09 PM, nursing documentation noted the nurse was notified of an event at 2:55 PM where he had "increased anxiety and was demonstrating aggressive behavior from internal stimuli toward other clients and staff." The medication nurse, ROC, and security were notified. At 3:05 PM, "Patient refused medication. Patient also refused morning medication this am as ordered." No other interventions were documented.
- On 03/07/21, the daily nursing progress note had no behaviors documented.
- On 03/07/21 at 6:37 PM, nursing documentation noted, "Patient violently assaulted another male peer unprovoked. He came up behind him and punched him and kicked him repeatedly. Male peer was seriously injured and bleeding from nose, mouth, and had eye swelling bilaterally. He kicked him in the stomach and back as well. Patient says that male peer was bothering him. He was making very rapid nonsensical statements. Patient needed to be restrained with board and body net restraints."
- On 03/09/21 at 7:04 AM, physician documentation noted that based on the recent extremely violent aggression towards another peer on the unit, the patient would be transferred to a higher security hospital on the morning of 03/10/21.

Review of two hospital video recordings titled, "Gym Cam1 and Gym Cam2," dated 03/7/21, showed two views of the gym. The review showed:
- 5:30:51 PM, Staff L, RN; Staff K, PT; and Staff PP, PT, were visualized at a table near the gym entrance. Staff KK, PT, was seated in the middle of the gym at a table against the wall.
- 5:30:55 PM, Patient #12 was seated in a chair at the far end of the gym. He appeared to be gesturing with his hands, speaking, and looking toward the area where staff were seated. Patient #8 was visualized pacing the end of the gym.
- 5:31:10 PM, Staff PP, PT, exited the gym.
- 5:31:20 PM, Patient #8 began pacing around the middle of the gym.
- 5:31:44 PM, Patient #12 pushed the tray table on the side of his chair down and continued to gesture with his hands and talk in the direction of staff.
- 5:32:03 PM, Patient #21 (who was on line of sight observation level) was seen coming out of the bathroom, unsupervised, and began walking the perimeter of the gym.
- 5:33:30 Staff KK, PT, exited the gym.
- 5:33:30 PM, Patient #8 continued to pace the gym.
- 5:34:07 PM, Patient #8 walked to the center of the gym and began to re-arrange a set of tables and chairs. Patient #12 still seated in the chair, continued to gesture and talk in the direction of staff.
- 5:35:01 PM, Patient #12 stood up from the chair and turned toward the area where staff were seated. He continued to gesture and appeared to be talking. He stomped his foot on the floor.
- 5:35:17 PM, Patient #12 walked toward the center of the gym and his behaviors continued.
- 5:35:48 PM, As Patient #12's behavior continued, Staff L, RN, exited the gym. Staff K, PT, remained seated at the table and was the only staff member in the gym with six patients.
- 5:35:56 PM, Patient #12 began to walk alongside Patient #8.
- 5:36:18 PM, Patient #8 continued to move objects in the middle of the gym. Patient #12's behaviors continued.
- 5:36:25 PM, Patient #12 walked up to Patient #8 and struck him in the face with a closed fist. Patient #8 fell to the ground.
- 5:36:27 PM, Staff K, PT, ran to the middle of the gym to intervene.
- 5:36:30 PM, Patient #12 walked around Patient #8, who was lying on the floor and began to stomp on his head.
- 5:36:33 PM, Staff L, RN, opened the gym door but did not enter. Staff NN, Security Officer, entered the gym. Patient #12 continued to stomp on Patient #8's head.
- 5:36:38 PM, Staff K, PT, pulled Patient #12 by the arm away from Patient #8.
- 5:36:40 PM, Staff K released Patient #12's arm as Staff NN, Security Officer, approached the area.
- 5:36:46 PM, Staff L, RN, and Staff PP, PT, re-entered the gym.
- 5:36:56 PM, Patient #12 began pacing and shoved a chair into a table. Staff NN, Security Guard, and Staff K, PT, did not intervene with Patient #12.
- 5:36:56, Patient #12 turned, walked toward the television and chair, turned around, and began walking back toward the middle of the gym.
- 5:36:59 PM, Staff L, RN, approached Patient #8 on the ground.
- 5:37:17 PM, Staff MM, Security Officer, entered the gym.
- 5:37:20 PM, as Staff L, RN, saw Patient #12 re-approach the area she stood up and walked away from Patient #8.
- 5:37:25 PM, Staff NN, Security Officer, was positioned on the right side of the Patient #8 and Staff MM, Security Officer, was positioned approximately four feet behind Staff NN. Staff K, PT, was positioned near to the right of Patient #8's head.
- 5:37:29 PM, Patient #12 approached Patient #8 from the left side and shoved a table out the way. As Staff K, PT, took a step forward, and Staff NN, stepped over Patient #8's body, Patient #12 stomped on Patient #8's head another time.
- 5:37:31 PM, Staff K, Staff NN and Staff MM lunged toward Patient #12, placed him in a manual hold, and put him on the ground.
- 5:37:34 PM, Staff L, RN, ran toward the gym door and hid behind a white curtain barrier where she remained before returning to assess Patient #8 at 5:38:05 PM. Patient #12 remained restrained on the gym floor.
- 5:37:35 PM, Patient #21 continued to walk the perimeter of the gym. Patients #33, #34 and #35 observed the incident from their beds and chair. (no staff appeared to be watching additional patients)
- 5:38:29 PM, Additional staff began to respond to the gym.
- 5:46:18 PM, Patient #21 continued to walk the perimeter of the gym, stepping between staff. Patient #35 was standing by his bed with two white objects in his hands. (no staff have interacted with the additional patients)
- 6:00:25 PM, Patient #21 continued to walk the perimeter of the gym, stepping between staff and Patient #12 lying on the floor restrained.
- 6:01:57 PM, Patient #12 was moved to a corner area in the gym and appears to be restrained. (at this time he was a 1:1 observation, Staff K, PT, at his bedside)
- 6:02:10 PM, EMS arrive in the gym to transport Patient #8 to the hospital.
- 6:13:58 PM, Police leave the gym. There were two PTs and no RN present in the gym. (There were five patients in the gym; two of the patients were 1:1 and line of sight; therefore, additional staff were required to monitor five patients)
- 6:18:17 PM, Patient #21 jogging the perimeter of the gym.
- 6:19:20 PM through 6:29:03 PM, Staff L, RN, or Staff QQ, RN, were present in the gym.
- 6:29:03 PM, Staff KK, PT, left the gym, leaving two staff members to monitor five patients.
- 6:37:20 PM, Staff KK, PT, returned to the gym, Staff L, RN, and Staff QQ, RN, exit the gym, leaving two PTs in the gym to monitor five patients; two of the patients were 1:1 and line of sight.

Due to the lack of nursing supervision and assessment, Patient #8 was seriously harmed and there was a potential for the remaining five patients to be harmed. Staff K, PT, who was assigned to monitor only one patient (Patient #21), was left by himself with six patients, in a gym, as Patient #12 was escalating and had recent aggressive behavior. Patient #12 then assaulted and injured Patient #8 when he hit him in the face and stomped on his head with his foot multiple times. After Staff K removed Patient #12 from Patient #8, Staff L, RN, who had left the gym earlier because she was scared of Patient #12, returned to assess Patient #8. Patient #12 got out of the manual hold and walked back toward Patient #8. Staff L, RN, left Patient #8 alone and hid behind a curtain, which resulted in Patient #8 being further injured by Patient #12. Staff did not remove Patient #12 from the immediate area or attempt to move the remaining patients out of the area as hospital policy stated. Patient #21 continued to walk the perimeter of the gym without supervision. After the incident was over, Patient #12 remained in the gym, restrained and on 1:1 observation. Patient #21 also remained on 1:1 observation. The video recording showed that there were only two PTs monitoring five patients, which left patients in an unsafe environment due to the lack of monitoring and supervision.

During an interview on 03/10/21 at 3:40 PM, Staff K, PT, stated that:
- New patients were placed in the gym upon admission for a 14-day COVID-19 (highly contagious, and sometimes fatal, virus) quarantine.
- The gym was only staffed with two or three PTs, depending on the census. If there was a LOS or 1:1 patient additional staff would need to be assigned to the gym.
- There was no nurse staffed in the gym. Nurses would only come to deliver patient medications or if they were called for assistance.
- There was no security staffed in the gym, they were stationed outside the gym doors.
- The day of the incident, 03/07/21, he was assigned a 1:1 with Patient #21. This was to be his only assignment.
- Patient #12 was unpredictable, at times he would become aggressive, but he was not a 1:1.
- He was the only staff member in the gym when Patient #12 attacked Patient #8.
- He could not restrain Patient #12 himself and had to wait for other staff to arrive.
- His training included Pro-ACT.
- He was not interviewed by the hospital in regards to this incident.
- He was not provided any education from the hospital in regards to this incident.

During an interview on 03/10/21 at 4:00 PM, Staff L, RN, stated that:
- The gym was used as a "transition" for patients who might have COVID-19.
- The night of 03/07/21, there were six patients in the gym.
- That census would require two PTs, but that night there were three because one patient was a 1:1.
- There was never a nurse assigned to work in the gym.
- There had been verbal and physical altercations in the gym prior to this incident but nothing that severe.
- She went to the gym around 5:30 PM to familiarize herself with the patients that would be coming to her unit.
- Staff K, PT, was assigned a 1:1 with another patient.
- She told Staff PP, PT, that she would stay in the gym and cover her so she could step out and get some food.
- Staff KK, PT, stepped out of the gym to use the restroom.
- Patient #12's behaviors escalated and she thought he was "going to run and rush me" so she stepped out of the gym and watched through the window.
- Staff K, PT, was going to re-direct Patient #12.
- When Patient #12 attacked Patient #8, she re-entered the gym and "pointed and yelled for someone to call 911."
- Staff KK, PT, called the front desk and told Security to call 911.
- Patient #8 laid on the ground for 30 minutes before anyone realized 911 had not been called.
- A 1:1 would be used for patients who were suicidal, unpredictable or could harm themselves or others. Patient #12 was one of those patients.
- She felt the admission screening of new patients was not thorough.
- She was not debriefed after this incident.
- She was not interviewed by the hospital in regard to this incident
- She was not provided any education after this incident.

During a telephone interview on 03/24/21 at 9:36 AM, Staff NN, Security Officer, stated that:
- Security posted outside the gym were to listen for calls of distress or anything that was unusual and assist if staff needed help.
- Nurses were not staffed in the gym and they would only come down to administer medicine.
- On 03/07/21, right before the incident, Staff L, RN, stepped out of the gym. When she stepped out of the gym he could hear yelling and he asked her what was happening. She stated that a patient was upset.
- She did not alert him to any need for intervention at that time.
- She walked back over to the window of the gym and saw Patient #12 attack Patient #8 and stated, "He just hit him."
- As Staff L re-entered the gym, he followed her but was not immediately aware of what had happened.
- He saw Staff K, PT, attempting to speak to Patient #12.
- He was unsure why Staff K did not attempt to restrain Patient #12, but assumed it was because he was the only staff in the gym, and he had also been assigned a LOS on another patient.
- He was not sure why there were no other staff in the gym.
- He was unable to place Patient #12 in a manual hold because when he entered the gym he had no knowledge of what Patient #12 had done prior and, "unless a patient was actively exhibiting an aggressive behavior, ProAct did not allow us to put them in a manual restraint."
- Patient #12 pushed through Staff K and kicked Patient #8 in the head again.
- That was when he and Staff K placed Patient #12 into a manual hold. Other staff had arrived to help at that time.
- Patient #12 was placed on a one-to-one after the incident and left in the gym on the restraint board.
- He felt that after the incident the scene was chaotic, which resulted in the ambulance not being called in a timely manner.
- A staff member had asked security to call 911; however, security cannot call 911 as they would not have been able to answer any questions the operator might have had about the incident.
- He felt that the gym was a "bad idea" and there was no clear leadership available to respond to incidents.
- After the incident he turned in a written statement to his supervisor but was not interviewed as part of an investigation.
- There was no education offered to security after this event.

During a telephone interview on 03/18/21 at 2:00 PM, Staff PP, PT, stated that:
- On 03/07/21, when PTs arrived for their shift, they received report that Patient #12 had refused his medication and had been verbally aggressive that day.
- Patient #12 was watching television and began to speak to it. He would then turn to the staff at the table and yell at them. She felt he was directing his aggression toward her.
- She called upstairs and reported his behaviors to Staff L, RN.
- Staff L, RN, came down to the gym and told her to go get dinner and that her absence might help the patient's behaviors.
- She was not present when the attack happened.
- Nurses were not staffed in the gym.
- She felt that the screening/intake process should be more rigorous as they admit dangerous clients that affect the rest of the clients on the unit.
- She was not interviewed by the hospital in regards to this incident
- She was not provided any education after this incident.

During a telephone interview on 03/16/21 at 2:25 PM, Staff KK, PT, stated that:
- When working in the gym, PTs' duties were to assist patients as needed.
- Patients could be admitted and start on a 1:1 or LOS instead of 15-minute rounds but it did not happen often.
- 03/07/21 was her first time working in the gym with Patient #12. She was unaware that he had been verbally and physically aggressive in the past.
- Patient #12 started yelling at Staff PP, PT, and kept stating that they knew each other. She was scared so Staff L, RN, told her to leave and that she would stay in the gym until she got back.
- She thought this would calm Patient #12 down.
- Everything was quiet so she asked Staff L if she could go use the restroom. While in the restroom, she heard screaming and yelling, and when she exited the restroom, she saw Staff L standing outside the gym door looking in.
- She asked what was happening and Staff L stated that patients were fighting. She knew that they needed to go back inside but Staff L was attempting to call an "Assistance Required" code using the wrong phone.
- Once inside the gym no one asked her to call 911.

During a telephone interview on 03/18/21 at 2:10 PM, Staff QQ, RN, stated that:
-She was outside on a fresh air break with patients when she heard an "Assistance Required" called for the gym.
- She knew there were three or four actively psychotic patients housed there at that time.
- When she arrived, Patient #12 had already been restrained and Staff L, RN, was with Patient #8 on the floor.
- When she realized the ambulance had not arrived she asked security if anyone had seen the ambulance and she was told security did not call 911.
- She started asking everyone who called 911, and no one answered, so she called 911.
- If an issue with a patient didn't directly concern a staff member there was no teamwork. Staff seem to want to push off their work to the next person and that was exactly what happened in the gym with the 911 call.
- She often saw PTs stand around when a situation becomes dangerous because they were scared.
- She felt that everything about the gym was unsafe.
- She felt the hospital was unsafe and she often felt helpless when she was there.
- Staff were not trained to remove themselves from a situation like Staff L, RN, did but she "understood why she did it, because staff were always being attacked and she was probably afraid that it would happen to her again."
- She could not recall any time where leadership had investigated an incident, interviewed staff on what happened or worked on improvements.
- She could not recall ever being debriefed or educated after any incident.

During an interview on 03/17/21 at 12:30 PM, Staff O, Medical Director, stated that:
- Upon admission, the physician would assign a level-of-observation to a patient based on the patient's current presentation, not on the patient's past history.
- Security were not continuously present on the units, and in the gym, as to not recreate the jail environment but to create a more therapeutic environment.
- If a patient became aggressive staff should first try to de-escalate then attempt a medication intervention. If the patient refused the medication, the nurse should call the physician for a possible one-time medication, or other intervention options.
- PTs should have no other assignments when doing a 1:1 or LOS observation.

During an interview on 03/17/21 at 10:40 AM, Staff N, Chief Nurse Executive (CNE), stated the following:
- He was ultimately responsible for the Nursing Department.
- His responsibility was to make sure processes and systems were in place to provide protective oversight of patients and staff.
- The gym was staffed with PTs and RNs would only come down to pass medication, perform a daily assessment, or help with patient's needs.
- If a PT reported to an RN that a patient had a change in behavior and was becoming aggressive, he expected the RN to immediately assess the patient and figure out what actions needed to take place.
- An RN should not leave an injured patient.
- He expected nursing staff to follow policy and procedures and to actively participate and engage during potentially dangerous situations.
- Staff assigned to monitor a patient 1:1 or line of sight, were responsible for that patient only and should not have other duties.

Based on interview, record review and policy review, the hospital failed to ensure that the Chief Nursing Executive (CNE) provided adequate oversight, supervision and evaluation of all nursing personnel, and failed to ensure that all nursing personnel knew and followed the hospital's policies and procedures. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's policy titled, "Nursing Scope of Service and Staffing Plan," dated 11/2016, showed the following:
- The CNE is the chief administrator of the Nursing Department.
- The CNE has the responsibility of organizing and planning overall nursing activities for the assessment of and the recommendation of numbers and mix of nursing staff to hospital administration for setting standards and development of policies and procedures.
- The CNE is the hospital's consultant regarding nursing issues and practice for hospital administration, unit managers, other disciplines and staff.
- Communication flows downward from the CNE and is facilitated through the written policies and procedures, as well as regularly scheduled meetings with Nurse Managers, supervisory staff and others as required.

Review of the hospital's policy titled, "Assistance Required," revised 04/2019, showed that Assistance Required is called by a staff member when more staff is required to handle a potentially dangerous situation. All available staff trained in crisis management are expected to respond when requested via overhead paging stating, "Assistance Required."

Review of the hospital's policy titled, "Adverse Events," dated 05/2019, showed:
- All adverse events as defined in this policy, shall have an incident report completed per hospital policy "Event Reporting," to initiate the review and documentation of due diligence in addressing the event.
- A timely, thorough, and credible Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) will be conducted and reported as required per this policy.
- The purpose of the policy was to provide a process for reviewing all adverse events that will ensure due diligence in review of adverse events. Will identify opportunities to reduce the risk of reoccurrence and focus the attention of the organization on understanding the causes that underlie the event and on changing processes and systems to reduce the probability of reoccurrence.
- Adverse events include those events identified by The Joint Commission as sentinel events. This includes major injury of another individual perpetrated by a patient.
- Following the occurrence of an adverse event, the facility will immediately provide prompt and proper medical and psychiatric care for any person affected by the adverse event.
- Following the occurrence of an adverse event, the facility will immediately contain the risk of reoccurrence.
- Following the occurrence of an adverse event, the facility the Chief Operating Officer (COO) may initiate a formal RCA and assign a RCA Team Leader and team members that shall consist of administrative staff and individuals directly identified as part of the event.
- If an RCA is initiated, the team will meet as soon as possible after the event to gather information about the event while the event is still fresh in the memory of those involved.
- The entire RCA process of review must be completed within 45 days.
- Adverse events and actions plans were reported to the Governing Body by the COO, Medical Director or the Quality Improvement Director at quarterly meetings of the Governing Body.

Review of the hospital's policy titled, "Event Reporting," dated 05/2019, showed the following:
- The hospital would document all unusual incidents, accidents, or injuries as established by the Department of Mental Health (DMH).
- The purpose of the policy was to prescribe procedures for reporting and recording critical incidents and other incidents.
- An event was defined as the unusual occurrence or event that led to an undesirable outcome which included but was not limited to physical altercation or injury.
- A critical event was defined as a significant incident involving department services, facilities, or patients that would be reported to key department administration.
- An event report would be completed during the shift in which the event occurred or was discovered by the person who observed or discovered the event.
- The completed and reviewed incident would be submitted to the department head or nurse manager who would check the form for completeness and accuracy. The department head or nurse manager would present the incident report in the next Incident Analysis (IA) meeting.
- The IA group would review the event unit, date, time, incident type, and description of each incident report completed since the previous IA meeting.
- The "Decision" section would be completed during the IA meeting at the direction of the COO.
- If the event was critical, as defined by DMH directive, the incident report would be reported to the COO's office as soon as possible following the occurrence of the event. The COO would determine the criticality of the incident and, if additional follow-up would be needed, the COO would direct the staff to complete the follow-up and report on findings within a specific period.

Review of the hospital's undated document titled, "Pro-ACT Participant Manual," showed the following:
- Pro-ACT emphasized team skills, not individual skills, and mirrored a teamwork experience.
- Always check with others before leaving an area, do not abandon team members.
- A lack of teamwork contributed to injuries.
- Failing to respond to and assist with assaultive incidents contributed to avoidable injuries to others.
- Managers were to provide employees with adequate supervision, security and training to avoid injuries to others.
- Potentially dangerous behaviors prior to a crisis included a change in appearance, change in demeanor or condition, and a change in activity level.
- Interventions used to avoid a crisis situation included addressing the client's needs (ask if they were tired, hungry, felt unsafe, thirsty, lonely, felt poorly or were in pain), reduce demands, and increase support by sitting together, taking a walk, having a conversation or offering reasonable choices to the patient.
- Determining baseline behaviors for each patient that staff were responsible for helped to assess possible indicators of impending dangers with patients.
- It was very important to be aware of the environment and take particular note of items easily used as weapons or items that could obstruct mobility.
- Employees who identified triggers, understood their own role in reducing the risk of escalation (an increase in the intensity or seriousness of conflict or potentially violent situation), and responded with safe alternatives during the escalation phase were better able to interrupt the cycle of assault and reduce the risks presented by crisis behavior.
- Debriefing was a key element in crisis prevention and included staff and patient perspectives.
- An assault crisis identified a treatment failure and debriefing was designed to evaluate the crisis and analyze why the plans did not work.
- Debriefing included staff and patients and should be supportive, constructive and focused on prevention of future crises.

Review of the hospital's document titled, "Pro ACT Aggression Management Training," dated 03/2016, showed the following:
- Prevention and management of aggressive and violent behavior was an essential skill for all staff.
- All staff were trained on an annual basis to provide patient care with a humane and respectful approach in a therapeutic environment.
- Physicians and Resident Physicians, Mental Health Managers, Nursing staff, Social Work staff, Rehabilitation staff, Psychologists, Security Officers, Clinical Pharmacists, Environment Services and Clinical Dietitians must recertify annually to maintain competency in Pro ACT.
- New employees must complete required Pro ACT training within three months of their employment.
- Supervisors and managers of patient care areas must assure that a sufficient number of certified staff were available.

Review of two hospital video recordings titled, "Gym Cam1 and Gym Cam2," dated 03/07/21, showed two views of the gym. The review showed the following:
- 5:30:51 PM, Staff L, Registered Nurse (RN); Staff K, PT; and Staff PP, PT, were visualized at a table near the gym entrance. Staff KK, PT, was seated in the middle of the gym at a table against the wall.
- 5:30:55 PM, Patient #12 was seated in a chair at the far end of the gym. He appeared to be gesturing with his hands, speaking, and looking toward the area where staff were seated. Patient #8 was visualized pacing at the end of the gym.
- 5:31:10 PM, Staff PP exited the gym.
- 5:31:20 PM, Patient #8 began pacing around the middle of the gym.
- 5:31:44 PM, Patient #12 pushed the tray table on the side of his chair down and continued to gesture with his hands and talk in the direction of staff.
- 5:33:30 PM, Staff KK exited the gym.
- 5:33:30 PM, Patient #8 continued to pace the gym.
- 5:34:07 PM, Patient #8 walked to the center of the gym and began to re-arrange a set of tables and chairs. Patient #12 still seated in the chair, continued to gesture and talk in the direction of staff.
- 5:35:01 PM, Patient #12 stood up from the chair and turned toward the area where staff were seated. He continued to gesture and appeared to be talking. He stomped his foot on the floor.
- 5:35:17 PM, Patient #12 walked toward the center of the gym and his behaviors continued.
- 5:35:48 PM, As Patient #12's behavior continued, Staff L, RN, exited the gym. Staff K, PT, remained seated at the table.
- 5:35:56 PM, Patient #12 began to walk alongside Patient #8.
- 5:36:18 PM, Patient #8 continued to move objects in the middle of the gym. Patient #12's behaviors continued.
- 5:36:25 PM, Patient #12 walked up to Patient #8 and struck him in the face with a closed fist. Patient #8 fell to the ground.
- 5:36:27 PM, Staff K stood up from the table and ran to the middle of the gym toward the patients.
- 5:36:30 PM, Patient #12 walked around Patient #8, who was lying on the floor, and began to stomp on his head.
- 5:36:33 PM, Staff L, RN, opened the gym door but did not enter. Staff NN, Security Officer, entered the gym. Patient #12 continued to stomp on Patient #8's head.
- 5:36:38 PM, Staff K, PT, pulled Patient #12 by the arm away from Patient #8.
- 5:36:40 PM, Staff K released Patient #12's arm as Staff NN, Security Officer, approached the area.
- 5:36:46 PM, Staff L, RN, and Staff PP, PT, re-entered the gym.
- 5:36:56 PM, Patient #12 began pacing and shoved a chair into a table. Staff NN and Staff K did not intervene with Patient #12.
- 5:36:56 PM, Patient #12 turned, walked toward the television and chair, turned around, and began walking back toward the middle of the gym.
- 5:36:59 PM, Staff L, RN, approached Patient #8 on the ground.
- 5:37:17 PM, Staff MM, Security Officer, entered the gym.
- 5:37:20 PM, as Staff L, RN, saw Patient #12 re-approach the area, she stood up and walked away from Patient #8 while he was still lying on the ground.
- 5:37:25 PM, Staff NN, Security Officer, was positioned on the right side of the Patient #8 and Staff MM, Security Officer, was positioned approximately four feet behind Staff NN. Staff K, PT, was positioned to the right of Patient #8's head.
- 5:37:29 PM, Patient #12 approached Patient #8 from the left side and shoved a table out the way. As Staff K, PT, took a step forward, and Staff NN stepped over Patient #8's body, Patient #12 stomped on Patient #8's head another time.
- 5:37:31 PM, Staff K, Staff NN and Staff MM lunged toward Patient #12, placed him in a manual hold, and put him on the ground.
- 5:37:34 PM, Staff L, RN, ran toward the gym door where she remained before returning to assess Patient #8 at 5:38:05 PM. Patient #12 remained restrained on the gym floor.
- 5:38:29 PM, Additional staff began to respond to the gym.
- 6:02:10 PM, EMS arrive in the gym to transport Patient #8 to the hospital.

Due to the lack of following policy, nursing supervision and assessment, Patient #8 was seriously harmed and there was a potential for the remaining five patients to be harmed. Staff K, PT, who was assigned to monitor only one patient (Patient #21), was left by himself with six patients, in a gym, as Patient #12 was escalating and had recent aggressive behavior. Patient #12 then assaulted and injured Patient #8 when he hit him in the face and stomped on his head with his foot multiple times. After Staff K removed Patient #12 from Patient #8, Staff L, RN, who had left the gym earlier because she was scared of Patient #12, returned to assess Patient #8. Patient #12 got out of the manual hold and walked back toward Patient #8. Staff L, RN, left Patient #8 alone and hid behind a curtain, which resulted in Patient #8 being further injured by Patient #12. Staff did not remove Patient #12 from the immediate area or attempt to move the remaining patients out of the area as hospital policy stated. Patient #21 continued to walk the perimeter of the gym without supervision. After the incident was over, Patient #12 remained in the gym, restrained and on 1:1 observation. Patient #21 also remained on 1:1 observation. The video recording showed that there were only two PTs monitoring five patients, which left patients in an unsafe environment due to the lack of monitoring and supervision.

During an interview on 03/15/21 at 11:35 AM, Staff C, Psychiatric Technician (PT), stated that he tried the best he could, but sometimes he had to run away from dangerous situations because the patient was scary.

During a telephone interview on 03/18/21 at 2:45 PM, Staff WW, Registered Nurse (RN), stated that when he worked at the hospital, staff ran and hid while he was being attacked. Staff would run and hide all the time when patients became aggressive.

During an interview on 03/16/21 at 9:30 AM, Staff DD, Nursing Manager, stated she had unit staff meetings quarterly but did not document what was on the agenda or discussed at the meetings.

During an interview on 03/17/21 at 10:40 AM, Staff N, CNE, stated the following:
- He was ultimately responsible for the Nursing Department.
- His responsibility was to make sure processes and systems were in place to provide protective oversight of patients and staff.
- Since Covid began he had not been going to the patient units.
- It was his responsibility to have regularly scheduled meetings with the nurse managers.
- He had not had Nursing Administration meetings with the nurse managers since early 2020, and it was his responsibility to have regularly scheduled meetings with them.
- His expectation was for the Nurse Managers to have monthly meetings, at a minimum, with staff and to document the meeting minutes.
- He expected the Nurse Managers to be active role models on the unit and to communicate to staff.
- He expected nursing staff to follow policy and procedures and to actively participate and engage during potentially dangerous situations.
- The gym was staffed with PTs and RNs would only come down to pass medication, perform a daily assessment, or help with patient's needs.
- If a PT reported to an RN that a patient had a change in behavior and was becoming aggressive, he expected the RN to immediately assess the patient and figure out what actions needed to take place.
- An RN should not leave an injured patient.
- He expected nursing staff to follow policy and procedures and to actively participate and engage during potentially dangerous situations.
- All event reports should be investigated and analyzed for trends.

The hospital failed to ensure that the CNE provided adequate oversight, supervision and evaluation of all nursing personnel and failed to ensure that all nursing personnel knew and followed the hospital's policies and procedures which resulted in a failure to protect patients from harming themselves, staff and each other. Additionally, the CNE failed to follow their own policy and investigate incidents, which allowed reoccurrences. There were 64 Event Reports from 01/01/21, until the time of the survey entrance. Administrative staff were not aware of the number of events that had occurred and admitted that their investigations did not include education to prevent reoccurrences.