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The hospital was found to be out of compliance with the Condition of Patient Rights. Based on interview and document review the hospital failed to protect each patient's rights when P2 assaulted P1 resulting in a fracture that required surgery.

Due to the serious nature of this failure the hospital is unable to ensure adequate Patient Rights.

Therefore, the hospital is unable to meet the condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include: See A144: Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) when the hospital failed to adequately supervise P2 who had a history of violence prior to admission and during his hospital stay, and P2 assaulted P1 resulting in P1 suffering a fractured nose that required surgical intervention.

Based on interview and document review, the hospital failed to provide care in a safe setting for 1 of 10 patients (P1) when the hospital failed to adequately supervise P2 who had a history of violence prior to admission and during his hospital stay, and P2 assaulted P1 resulting in P1 suffering a fractured nose that required surgical intervention.

Findings include:

P1's Face Sheet dated 12/23/21, indicated P1 was admitted to the hospital on 12/23/21, with diagnoses that included suicidal ideation and schizoaffective disorder.

P1's Admission Assessment dated 12/23/21, indicated he was at moderate risk for suicide, and was placed on routine supervision.

On 12/29/21, P1's progress notes indicated P1 was attacked by a peer and experienced a broken nose.

On 1/4/22, P1's progress note indicated P1 had surgery related to the broken nose he suffered in the attack by P2.

P2's Face Sheet dated 12/12/21, indicated P2 was admitted to the hospital on 12/12/21, with diagnoses that included behavioral problems and schizoaffective disorder.

P1's History and Physical (H & P) dated 12/12/21, indicated P2 was admitted to the facility after he became violent in his group home, and staff had to call 911 related to the violence. P2's H & P further revealed P2 had a history of violence, and had instigated a fight at another local hospital in the last week before admission. P2 was placed on routine supervision.

P2's progress notes indicated P2's behavior was escalating:
On 12/25/21, P2 became violent and threw a remote control after breaking it in half with his hands. A Code Green (a code indicating a violent patient who requires more staff for intervention) was called in response to the incident. No increase in supervision was initiated.
On 12/26/21, P2 attempted to assault a peer unprovoked, and staff had to intervene to stop the assault. The peer was moved, but no increase in P2's supervision for safety was initiated.
On 12/27/21, P2 was refusing medications, responding to internal stimuli and pacing the halls.
On 12/28/21, P2 was upset regarding a court decision and refusing interaction with staff and peers.
On 12/29/21, at 7:38 a.m. P2 attacked P1, unprovoked. P1 fell to the ground and suffered a broken nose.

Although P2's behavior was escalating and P2 exhibited violence in property destruction and an unprovoked attempted assault prior to 12/29/21, the hospital did not increase P2's supervision, and P2 later attacked P1.

During an interview on 1/6/22, at 12:00 p.m. P1 stated P2 stuck him in the face in an unprovoked assault. P1 stated he thought the incident should not have occurred as he heard P2 had been chasing people around the unit, and staff should have been watching him better.

During an interview on 1/6/22, at 1:53 p.m. registered nurse (RN)-D stated he had cared for P2 recently. RN-D stated prior to assaulting P1, P2 was pacing the halls, and constantly seemed agitated.

During an interview on 1/6/22, at 2:25 p.m. RN-E stated P2 was not on increased supervision after the first attempted assault, because the intensive treatment unit was full and there was no place for P2 to go. RN-E stated she was working on 12/29/21, when P2 attacked P1. RN-E stated P2 was pacing the halls and had a high potential for violence prior to the assault, and other patients were fearful of P2. RN-E stated P2 attacked P1 unprovoked knocking him to the ground. RN-E stated after P1 fell, he was bleeding profusely. P2 was then put in seclusion and law enforcement took him into custody later that day.

During an interview at 1/7/22, at 10:00 a.m. P2's physician (MD)-F stated P2 had attempted to assault a peer on 12/26/21. After such an event the staff usually separate the patients (which was done) and move the assault patient to an area for increased supervision (intensive treatment area). MD-F stated unfortunately on 12/26/21, when P2 attempted to attack a peer, there were no beds available in the intensive treatment area, so no increase of supervision of P1 was initiated.

Video of the assault was reviewed on 1/6/22, at 1:20 p.m. In the video dated 12/29/21, at 7:39 a.m. P1 was directly in front of the nursing desk, and P2 was on the phone about 20 feet from the nursing desk. P2 hung up the phone, walked quickly up to P1, and hit him in the face. At the time, four staff members were behind the desk, one staff member was doing rounds, and no staff were with the seven patients in the common area in front of the desk.

The facility policy Threat Assessment dated 10/17, directed threats of violence against (hospital) staff, visitors, patients, physicians and volunteers will be taken seriously and will be assessed and managed to prevent or mitigate violent acts. The hospital will cooperate with law enforcement agencies in the investigation of any threat of violence to the furthest extent allowed by patient confidentiality and Human Resources law and practices.