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Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when a staff mental health associate (MHA)-A verbally and physically assaulted P1. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition level deficiency was issued.

Findings include:

See A-0144; Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when a staff mental health associate (MHA)-A verbally and physically assaulted P1. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) reviewed when a staff mental health associate (MHA)-A verbally and physically assaulted P1. This deficient practice resulted in an immediate jeopardy (IJ) for P1.

The IJ began on 5/1/23, at approximately 3:15 p.m. when P1 exited his room, and pushed his door aggressively towards mental health associate (MHA)-A. MHA-A stopped the door from swinging. P1 walked towards MHA-A, and they both engaged in a verbal altercation. P1 attempted to punch MHA-A, but did not make physical contact with MHA-A. MHA-A responded by punching P1 in the face. MHA-A continued to be the aggressor, and pushed P1 back into the wall and struck/punched P1 again. The program manager accreditation & regulatory compliance (PMARC), interim vice president of quality (IVPQ), vice president of quality operations (VPQO), and director of quality improvement (DQI) were notified of the notified of the IJ finding on 5/11/23, at 3:10 p.m.

Findings include:

A Vulnerable Adult Maltreatment Report, dated 5/3/23, was submitted by the hospital which outlined P1 presented to the mental health emergency department (ED) crisis unit on 5/1/23. The report included a description of the incident as follows: Patient was being seen in room G4. Staff member went to respond to call light, upon leaving the room, the patient shoved the door open aggressively. MHA-A stopped the doorway and patient walked towards staff. Staff attempting to de-escalate patient and punched staff member in the face. Staff immediate response was a punch back. An emergency response was called and a RN and security officer present to respond to incident. During the take down of patient, additional force including shoving and punch was used by MHA-A to gain control of the patient attack towards staff member. MHA-A was removed from the care area immediately after incident.

P1's Emergency Medicine Visit Note dated 5/1/23, indicated P1 was a 25-year-old male admitted to the mental health emergency department (ED) crisis unit for a crisis evaluation. P1's diagnoses included suicide attempts, borderline personality disorder, mood disorder, and generalized anxiety disorder.

P1's Emergency Medicine Visit Note dated, 5/2/23, indicated P1 had no obvious injuries from the altercation with MHA-A and P1 refused any additional physical examinations. On 5/2/23 at 2:28 a.m., P1 was discharged from the mental health crisis ED unit.

On 5/10/23 at 10:40 a.m., video review of the mental health crisis ED with manager of quality improvement (MI), manager of security (MS) and director of security (DS) revealed the following: On 5/1/23, at 3:15 p.m. P1 exited his room and pushed his door aggressively towards MHA-A. MHA-A stopped the door from swinging, P1 walked towards MHA-A, and the two engaged in a verbal altercation. Registered nurse (RN)-A arrived and attempted to de-escalate and separate MHA-A and P1 by placing his arm between them. Security officer (SO)-A arrived and placed his arm between P1 and MHA-A to de-escalate and separate P1 and MHA-A. MHA-A continued to engage in a verbal altercation with P1. P1 attempted to punch MHA-A, but did not make physical contact. MHA-A responded by punching P1 in the face. MHA-A continued to be the aggressor and pushed P1 back into the wall. MHA-A struck/punched P1 again, even though SO-A had already initiated a takedown of P1. RN-B arrived and instructed MHA-A to TAP OUT (physically remove oneself from an area) and remove himself from the situation.

On 5/10/23 at 1:28 p.m., RN-B stated she had initiated a Code Purple (call for security) when P1 and MHA-A were observed in the hallway face-to-face. RN-B stated when she came out into the hallway, MHA-A was on top of P1. RN-B stated she instructed MHA-A to get off of P1 three times before he did, and removed himself from the area and off the unit.

On 5/10/23 at 2:34 p.m., SO-A stated he was assigned to the mental health crisis ED unit on 5/1/23. SO-A stated he heard a nurse say, "Oh we cannot have that." SO-A stated he went out into the hallway where P1 and MHA-A were face-to-face. SO-A stated he put his arm between P1 and MHA-A to de-escalate the situation. SO-A stated P1 and MHA-A were talking back and forth, and he heard P1 saying to MHA-A, "Hit me, hit me." SO-A stated P1 then threw a punch towards MHA-A, and he took P1 down to the ground. SO-A stated during the take down of P1, he was unaware of anything else going on around him, including MHA-A punching P1.

On 5/10/23 at 4:49 p.m., MHA-A was interviewed and stated P1 had been using his call light continually. MHA-A stated he entered P1's room to see if P1 needed anything and P1 began cursing at him. MHA-A stated P1 got up from his bed and he exited P1's room. MHA-A stated P1 swung open his door into the hallway; however, the door did not hit him. P1 then lunged towards him and was right in his face. MHA-A stated P1 continued to call him names. MHA-A-A stated he was not going to allow P1 to hit him. MHA-A-A stated P1 continued to call him names, and then P1 swung at him. MHA-A stated he remembered his adrenaline going, and he responded "with force." MHA-A stated the next thing he remembered was tackling P1 to the floor. MHA-A-A stated he had no recollection of hitting P1 until he was told he had done so. MHA-A-A stated he had resigned from his position at the hospital, "It was either I quit, or I was going to be terminated."

On 5/10/23 at 2:47 p.m., RN-C (the director of the ED), IVPQ, and PMARC were interviewed. RN-C stated the facility had not provided additional training or education to staff after this incident other than a weekly email/memo which went out to the ED staff. RN-C stated this did not include specific training reeducation related to abuse prevention and patient care in a safe setting.

On 5/11/23 at 8:08 a.m., P1 was interviewed and stated a male staff had entered his room in the ED on 5/1/23. P1 stated the staff person made statements such as, "Do you think you are a man?" and was standing over him while he was lying in bed. P1 stated he asked the staff why he was doing this, and the next thing he remembered was he was on the floor with staff on top of him. P1 stated he had no recollection of the physical altercation, and did not receive any injuries.

The hospital's Preventing, Identifying, Investigating, and Reporting Maltreatment of a Vulnerable Adult Policy dated 8/19/21, directed the purpose of the policy was to prevent, identify, investigate and report maltreatment of a vulnerable adult. Patients have the right to be free from all forms of maltreatment (abuse, financial exploitation, neglect).

The IJ was removed on 5/15/23, at 1:45 p.m. when it was verified the hospital had submitted and implemented an acceptable removal plan which included appropriate education and training of all employees, including mental health workers. This was verified through interview and policy review.