The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY May 22, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, and review of the facility's policies and documents, it was determined the facility failed to provide care in a safe setting for two (2) of ten (10) sampled patients (Patients #1 and #6).

The facility admitted Patient #1 on 04/25/14, with diagnoses which included Impulse Control Disorder and Borderline Intelligence Quotient (IQ). Patient #1 was admitted on a court ordered involuntary hold. Review of Patient #1's medical record revealed the patient had a history of being easily agitated, manipulative and prone to outbursts.

On 05/11/14, Mental Health Associate (MHA) #1 was assigned to close observation, within clear view and twelve (12) feet of the patient at all times, of Patient #1. Review of the facility's video recording revealed an incident of verbal altercation involving MHA #1 and Patient #1 occurred at approximately 8:54 on 05/11/14. Staff responded with some staff stepping in between the Patient #1 and MHA #1. Registered Nurse (RN) #1 was observed to come to assist with the situation, and MHA #3 and MHA #8 left the incident area, leaving MHA #1 and RN #1 with Patient #1. Interviews revealed MHA #1 was observed to be verbally abusive towards Patient #1. According to interviews at approximately 8:59 AM, staff responded to the "yelling" of MHA #1 and Patient #1; however by the time they responded, the incident had escalated out of control. Continued observation of the video revealed Patient #6 was observed to be walking in the hallway near where the incident was occurring, when MHA #1 threw a cup of liquid on the floor, in Patient #6's path. Review of the facility's Crisis Prevention Intervention (CPI) protocol revealed when an incident occurred patients should be placed in a "safe" area, away from the incident, while it was occurring. The facility's failure to ensure care was provided in a safe setting created a potentially harmful situation for Patient #1 and Patient #6. (Refer to A0144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of the facility policies and procedures, documents and video recording, it was determined the facility failed to ensure patients were in a safe environment for two (2) of ten (10) patients (Patient #1 and Patient #6).

The facility failed to ensure Patient #1 was removed Mental Health Associate (MHA) #1's care when the patient and MHA became engaged in a verbal altercation which escalated to verbal abuse of Patient #1 by MHA #1.

The facility failed to ensure Patient #6 was in a safe area and protected from the potential for harm during the verbal altercation between Patient #1 and MHA #1. Patient #6 was allowed to walk in the hallway near the area of the verbal altercation and MHA #1 threw a cup of liquid on the floor and almost ran into the patient. Patient #1 had to step over the spilled liquid on the floor.

The findings include:

Review of the facility's policy, titled, "Patient Rights and Responsibilities", revised 03/13/14, revealed the purpose of the policy was for the facility staff and contract staff to observe patients' rights. Continued review of the policy revealed patients had the right to considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation.

Review of the facility's policy titled, "Incident Management: Protection of Patients from Abuse, Neglect, Exploitation, Harassment, and Injury", revised 02/27/14, revealed the purpose of the policy was to commit to the provision of services in a caring and hospitable environment that was free from harm for the patient, the visitor and staff. Review of the policy revealed the facility's Risk Management Program was to create a safe environment through effective incident management.

Review of the facility's Crisis Prevention Intervention (CPI) workbook, titled, "Nonviolent Crisis Intervention", copyright 2005, and review of the CPI training handouts, dated 2014, revealed there were two (2) ways a hostile person vented his/her aggression or hostility, verbally and physically. Review revealed should a patient escalate verbally, staff should remove them from the area. The CPI documents revealed if a patient intimidated staff verbally or nonverbally they should take the threats seriously and get assistance from other staff. Further review revealed staff should try to avoid individually intervening as this would more likely jeopardize the safety and welfare of both staff and the patient.

Observation of the facility's video surveillance recording, dated 05/11/14, revealed no audible sound could be heard; however, it could be viewed. The video began at 8:54:05 AM, and MHA #1 and Patient #1 were observed to enter the patient's room. The video revealed at 8:55:08 AM, MHA #3 was observed to walk in the direction of Patient #1's room and at 8:55:10 AM, MHA #1 was observed to exit the patient's room and converse with MHA #3, then MHA #1 left the area and walked towards the nurse's station. Continued review of the video revealed MHA #1 was observed with a cup in her hand at 8:55:43 AM to be walking toward's Patient #1's room. Review of the video revealed MHA #1, MHA #3, MHA #7, and Patient #1 were standing in the hallway, near the patient's room. Observation of the video revealed Patient #1 walked near to MHA #1, approximately within a foot of her, as MHA #3 and MHA #7 stood between the patient and MHA #1. MHA #3 was observed to separate MHA #1 and Patient #1. At 8:55:25 AM, the patient was observed to turn and walk towards his/her room and MHA #3 was noted to grab his/her arm, causing the patient to turn converse with her. At the same time, MHA #1 was observed to walk away leaving MHA #3 and MHA #7 with the patient. At 8:56:40, MHA #7 then walked away from Patient #1's room. Continued observation of the video revealed at 8:56:59 AM, MHA #1 returned to Patient #1's room with Registered Nurse (RN) #1/Charge Nurse. Observation of the video revealed MHA #1 stood in the hallway outside of Patient #1's room, drinking from a cup and was observed holding a clipboard in her other hand. RN #1/Charge Nurse was observed to converse with Patient #1 while MHA #1 and MHA #3 stood in the doorway. At 8:58:19 AM, MHA #3 left area of Patient #1's room and walked towards the nurse's station leaving MHA #1 and RN #1 with Patient #1. At approximately 8:58:40 AM, MHA #1 entered Patient #1's room while, RN #1 stood in the doorway, with her back to the camera. At 8:58:44 AM, MHA #1 was observed coming out of Patient #1's and paced in the hallway while RN #1 remained at the patient's doorway. At 8:59:05 AM, MHA #1 re-entered Patient #1's room, while RN #1 continued to stand at the door looking into the room. At 8:59:13 AM, MHA #8 was observed to come out of the room next door to Patient #1's room and MHA #2 was observed to come down the hallway towards the patient's room. MHA #8, MHA #2, and RN #1, were observed to stand in the doorway of Patient #1's room. At the same time, MHA #1 was observed leaving Patient #1's room and to throw a cup filled with liquid on the floor as Patient #6 was walking by in the hallway and this patient almost ran into MHA #1. Continued observation of the video revealed Patient #6 had to walk through the spilled liquid on the floor and MHA #1 was observed to walk away from Patient #1's room.

1. Record review revealed Patient #1 was admitted to the facility on [DATE] with diagnoses which included Impulse Control Disorder, Borderline Intelligence Quotient (IQ) and Asthma. Continued review of Patient #1's record revealed Nurse Shift Assessments which indicated the patient's behavior/mood consisted of being easily agitated, instigates, manipulative, attention seeking, pushes limits, sarcastic, labile, prone to outbursts, loud at times, intrusive and staff splitting.

2. Review of Patient #6's medical record revealed he/she was admitted to the facility on [DATE], with diagnoses which included Mood Disorder, Major Depressive Disorder, Anxiety Disorder and Post Traumatic Stress Syndrome.

Review of the facility's investigation dated 05/11/14, revealed MHA #1 written statement, dated 05/11/14, revealed she was assigned to close observation (remaining within twelve feet and clear view of the patient) of Patient #1 at 7:30 AM that morning. MHA #1 documented Patient #1 would not allow her to provide requested items and walked away and did not speak to her. MHA #1 noted Patient #1 took a shower in his/her room where she told the MHA to "shut her...mouth" and he/she left the room. MHA #1 documented Patient #1 continued this behavior and eventually returned to his/her room where Patient #1 began to make verbally threatening statements to her, and pointed his/her finger in her face. Continued review of the written statement revealed MHA #1 noted she attempted to block Patient #1's hands away from her face; however, the patient continued the behavior. MHA #1 documented she was able to get to the patient's door and "walked out" of the door to tell other staff standing there to "get" Patient #1. MHA #3 intervened and attempted to calm Patient #1 and RN#1/Charge Nurse also came to the patient's room. Review of the written statement revealed Patient #1 explained to RN #1 what happened and made "false allegations" against MHA #1 suggesting she had "pulled" his/her hair. MHA #1 noted Patient #1 continued to threaten her, and stated, "Come on, hit me right here." Further review of the statement revealed MHA #1 informed Patient #1 she was not going to fight him/her. MHA #1 noted RN#1 attempted to calm Patient #1 down and MHA #3 was going to take over the patient's care. Review of the written statement revealed MHA #3 needed to get something from the break room and while MHA #1 was "standing there" with her clipboard and coffee in hand, Patient #1 continued to make verbal threats and allegations about her. MHA #1 noted while "standing there, boiling", she had gotten "emotionally upset" and squeezed her coffee cup and threw the clipboard down and "walked out".

Phone interview was attempted on 05/22/14 at 8:01 PM with MHA #1 without success.

Interview with Patient #1, on 05/21/14 at 2:42 PM, revealed on 05/11/14, MHA #1 was telling him/her to "shut the f...up" while he/she was in his/her room and no one saw it. Patient #1 reported MHA #1 was being disrespectful towards him/her and slammed the bathroom door trying to smash his/her fingers. Patient #1 stated she said to MHA #1, "was that supposed to scare me?" Continued interview with Patient #1 revealed he/she got into a physical altercation with MHA #1 and he/she "yelled" for help, but staff did not respond. Per interview Patient #1 reported when the physical altercation ended MHA #1 went into the hallway and two (2) staff members responded, MHA #5 and MHA #7. Patient #1 reported he/she returned to his/her room where the situation got "heated" again and a verbal argument ensued between him/her and MHA #1. Patient #1 stated MHA #1, threw her clipboard at him/her and hit him/her in the leg. According to Patient #1, MHA #1 then left his/her room throwing her cup of coffee on the floor.

Interview with Patient #6, on 05/21/14 at 4:15 PM, revealed he/she recalled the incident which occurred on 05/11/14. Patient #6 stated he/she was walking towards his/her room and saw MHA #1 throw her coffee and "yell" she was frustrated.

Interview with MHA #5, on 05/21/14 at 3:00 PM, revealed on 05/11/14 she was at the nurse's station and heard a lot of "yelling" and went to get RN #1/Charge Nurse. She stated she asked MHA #2 to assist with de-escalating the situation. She revealed she did not witness the incident in it's entirety, due to being at the nurse's station. However, she reported she saw the coffee on the floor after the incident. Continued interview with MHA #5 revealed the safety concern with the other patient being in the area when the coffee was thrown by MHA #1, could have resulted in it being thrown on him/her, or other patients or staff could have slipped on the coffee and fallen.

Interview with MHA #2, on 05/21/14 at 3:39 PM, revealed she recalled the incident on 05/11/14. MHA #2 reported the incident occurred close to 9:00 AM, when she heard yelling down the hallway, coming from Patient #1's room. She stated MHA #5 asked her to assist MHA #1, who was already in the patient's room. Per interview, MHA #2 saw the RN #1/Charge Nurse standing at the door to Patient #1's room with MHA #1. She reported she heard the patient state, "you don't have to put your hands on me." Continued interview with MHA #2, revealed she heard MHA #1 respond by saying, "I did not touch you, I put my chest on you." MHA #2 stated she observed MHA #1 throw her clipboard down, towards the ground, not towards Patient #1. She reported she observed MHA #1 leave Patient #1's room, throwing her coffee, and stating, "f... this, I don't need this." According to MHA #2, the proper way to de-escalate a patient would be to talk to the patient and try to calm him/her down, or sometimes would have to walk away, and send someone else to take over. She reported if she could not de-escalate the patient, she would get the nurse because the patient might need medication. MHA #2 indicated none of these procedures were followed, after RN#1/Charge Nurse was called to assist/assess the situation. She stated she believed RN #1/Charge Nurse should not have allowed the situation to get as far as it did and should have "hollered" for someone to come help. She reported RN #1/Charge Nurse did not call for anyone to intervene, which escalated the situation and created an unsafe environment for the patient and staff. She stated RN #1/Charge Nurse was not saying anything and indicated she just stood there. MHA #2 revealed she told MHA #1 to walk away, but by then the situation had gone too far. Continued interview with MHA #2 revealed she wished she could have been there at the patient's room to assist in the beginning. Further interview with MHA #2, revealed staff received training on the facility's CPI protocol, which indicated staff were to remove patients from the area of the verbal and/or physical altercation to keep the situation under control and prevent another "situation" from occurring. MHA #2 stated Patient #6 should not have been allowed in the area during the verbal altercation between Patient #1 and MHA #1.

Interview with MHA #3, on 05/21/14 at 4:42 PM, revealed she heard Patient #1 "yelling" at MHA #1, "taunting" her and trying to get MHA #1 to fight, and was accusing the MHA of pulling her hair. She reported she explained to Patient #1 that yelling would not solve the problem and asked him/her if he/she wanted her to take over care of him/her; however, the patient stated he/she did not want her to take over. MHA #3 stated she left Patient #1's room, and thus did not see all of the incident and reported the last thing she heard was "screaming" and MHA #1 leaving the unit, crying. Continued interview revealed when a patient has escalated in behavior, staff were to step in to assist by switching over care. She stated she did not switch over because when she asked Patient #1 if she wanted her to take over his/her care ten (10) minutes earlier, the patient said no. She reported she could not remember if RN #1/Charge Nurse did anything.

Interview with RN #1/Charge Nurse, on 05/22/14 at 7:20 PM, revealed the facility's process was to de-escalate situations and make the environment safe for patients. She reported staff should always try to de-escalate situations by "minimizing" them, and if the situation still could not be controlled, then security should be called. RN #1/Charge Nurse revealed on 05/11/14, she was told by another staff member of an altercation going on between MHA #1 and Patient #1. She reported when she went back to the patient's room, Patient #1 was making accusations towards MHA #1, and MHA #1 "flew off the handle" getting "nose to nose" with the patient, and said "horrible" things to him/her. Continued interview revealed she thought of placing her hands on the MHA #1, but was unsure of what would happen if she did. RN #1/Charge Nurse reported MHA #1 then threw her clipboard at Patient #1 and threw her coffee on the hallway floor and walked off. According to RN #1/Charge Nurse she had been trained on the facility's CPI process, and indicated CPI trains staff the proper steps to intervene with patients when going from a verbal to a "full blown out hands on" with the patient. She stated with CPI staff should try to de-escalate a situation involving verbal and/or physical altercations. RN #1/Charge Nurse stated in regards to the incident involving Patient #1, she did not feel as though the facility's CPI process had been followed. RN #1 revealed she was not aware Patient #6 was near the incident when the coffee was thrown; but, stated his/her room was down the hall from Patient #1's room.

Interview with MHA #4, on 05/21/14 at 5:53 PM, revealed she did not witness the incident. She added she was on close observation with another patient. MHA #4 revealed the process for intervening when a staff member gets into a verbal and/or physical altercation with a patient was to try to de-escalate the situation. If the patient and/or staff did not calm down, the nurses were supposed to intervene. MHA #4 indicated should the patient continue to escalate, the Physician would be notified for possible medication orders.

Interview with Licensed Practical Nurse (LPN) #1 on 05/22/14 at 6:50 PM, revealed she did not witness the incident. She reported she was in the medication room and initially thought the "yelling" was coming from Patient #1, not MHA #1. LPN #1 indicated she did not respond to the incident. She stated in a situation where a staff member was in a verbal and/or physical altercation with a patient, staff members should separate the patient and the staff member involved. She reported the staff member involved should leave the unit while staff attempted to calm the patient down. LPN #1 revealed this would be done so no staff and/or patient would get hurt. According to LPN #1, staff should try to get all other patients away from the area of the incident for their safety. She stated staff should send the patients to their rooms or to another area.

Interview with RN #3, on 05/22/14 at 5:34 PM, revealed he did not witness the incident on 05/11/14, between MHA #1 and Patient #1. He reported every staff member was provided training in the facility's CPI process. RN #3 stated if an altercation broke out between a staff member and patient, staff should take the patients who were not involved into a different area, away from the incident for their protection. Continued interview with RN #3 revealed leaving a patient near an incident area would create a dangerous situation for the patient, as in this case which involved Patient #1 and Patient #6. He added the crisis situation would increase which would increase the danger.

Interview with Senior Nursing Administrator, on 05/22/14 at 6:39 PM, revealed it would be his expectation staff would defuse any situation by removing the danger and prevent any harm. He stated in this case involving Patient #1 and MHA #1, it would have been necessary to remove MHA #1 off the unit. Continued interview with the Senior Nursing Administrator revealed staff should try to keep patients away from the area of an incident, when a physical and/or verbal altercation occurred. He reported the facility's CPI training addressed removing the "focus of the acting out" or threatening behavior to lessen the exacerbation of the situation, adding the "acting out" person might be fueled by having an audience. The Senior Nursing Administrator stated he could see where Patient #6 would have "gotten through" to the incident area, as the staff were assisting with Patient #1 and not observing for other patients in the area. Further interview with the Senior Nursing Administrator revealed the safety of the staff, as well as, patients were heightened due to a break-down in the facility's CPI protocol.

Interview with the Director of Risk Management, on 05/22/14 at 7:39 PM, revealed staff should try the least restrictive intervention with the patient first. She reported this would be to de-escalate the patient and she believed this was done successfully with Patient #1. Continued interview revealed in any incident, the facility's CPI protocol required patients be re-directed out of the area of the incident for the safety of the staff, as well as, the patient. In regards to Patient #6, she reported the facility's CPI protocol should have been followed and the patient should have been kept away from the incident area. The Director of Risk Management stated MHA #1 had been terminated from employment with the facility.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and review of the facility's policies and procedures and Crisis Prevention Intervention (CPI) documents, it was determined the facility failed to provide adequate nursing supervision for one (1) of ten (10) sampled patients (Patient #1).

Patient #1 was admitted on [DATE], with diagnoses which included Borderline Intelligence Quotient (IQ), Impulse Control Disorder, and Asthma. Continued review revealed Patient #1 was admitted on an involuntary hold which was court ordered, and nurse's documented the patient's behavior as being easily agitated, loud at times and prone to outbursts.

Interviews with staff revealed on 05/10/14, Mental Health Associate (MHA) #1 was observed redirecting Patient #1, Patient #2, and Patient #3 away from the nurses station because the patients had gotten too loud. Patient #1 told staff of his/her dislike towards MHA #1 and was verbally "threatening" towards MHA #1. MHA #1 informed Registered Nurse (RN) #3 and RN #5 of her frustration with working with Patient #1 and RN#5, who was the Charge Nurse, gave MHA #1 another patient assignment. Interviews with staff revealed on 05/11/14, MHA #1 was again assigned Patient #1's care and expressed to peers her apprehension with caring for Patient #1. Staff interviews revealed Patient #1 was on "close" observation supervision level which indicated staff caring for him/her were to remain within clear view and within twelve (12) feet of the patient. Interview with MHA #2, revealed MHA #1 indicated she felt "they" were trying "to set her up." Interviews with RN #2, RN #3, MHA #2, and MHA #5 revealed MHA #1 appeared stressed and was not her normal "upbeat" self. Interviews with MHA #2, MHA #3, and MHA #5 revealed MHA #1 should not have been assigned to Patient #1's care on 05/11/14, as she appeared stressed and not her normal self and as she had expressed her frustration with caring for the patient to the nurses on 05/10/14.

Review of the facility's policy revealed the facility was "committed to maintaining a healthy work environment by educating staff about the negative impact of potentially traumatic workplace stress". Review of the Charge Nurse Responsibilities document revealed the Charge Nurse was to assess staff performance and provide guidance to staff as appropriate.

On 05/11/14 at approximately 9:00 AM, staff reported to the Charge Nurse that Patient #1 and MHA #1 were in a verbal altercation which could be heard throughout different areas of the unit. RN #1, the Charge Nurse, walked to Patient #1's room with MHA #1; however, failed to call for additional staff assistance to diffuse the situation which left MHA #1 responsible for Patient #1. Interviews revealed MHA #1, was observed to become verbally aggressive towards Patient #1, after the patient continued to make allegations of physical abuse against MHA #1. Review of the facility's video recording revealed the Charge Nurse did not call for additional staff to assist with Patient #1. Interviews revealed staff responded only to the continued "yelling" of Patient #1 and MHA #1. (Refer to A0395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview, record review and review of the facility's policies and procedures and documents, it was determined the facility failed to ensure nursing services adequately supervised and evaluated the care of patients for one (1) of ten (10) sampled patients (Patient #1). The facility's nursing staff failed to assess and monitor staff who were providing care for patients to ensure they were not experiencing possible increased stress and burn-out which could lead to abusive situations involving patients.

Mental Health Associate (MHA) #1 expressed frustration with caring for Patient #1 on 05/10/14. However, MHA #1 was assigned to Patient #1's care again on 05/11/14, and became involved in a verbal altercation with the patient which lead to alleged verbal abuse of him/her by MHA #1. Additionally, the facility's nursing staff failed to request additional staff assistance for MHA #1 to allow her to leave the area and de-stress and to attempt to de-escalate Patient #1's behavior.

The findings include:

Review of the facility's document titled, "Charge Nurse Responsibilities", undated, revealed the Charge Nurse was the first level of unit supervision assigned during their assigned shift. Review of the document revealed the Charge Nurse was assigned patient care responsibility and the responsibilities included organizing, prioritizing and delegating work flow. Further review revealed the Charge Nurse was to adapt the work plan to changes in unit workload, assess staff performance and provide guidance to staff members as appropriate.

Review of the job description for the "Charge Nurse", with an effective date of 01/12/14, revealed when in the Charge Nurse role, nurses were to manage staff, including but not limited to making patient care assignments, monitoring patient flow, and identifying unusual occurrences as policies required.

Review of the facility's policy titled, "Crisis Response Team for Staff", revised 04/22/14, revealed the facility was committed to maintaining a healthy work environment by educating staff about the negative impact of potentially traumatic workplace stress. A Crisis Response Team was available to minimize the impact of potentially traumatic workplace stress on staff and provide basic information on coping strategics to reduce stress and promote adaptive functioning. Additional review revealed to activate the process, staff were to notify the Nurse Manager or Department Heads in the Nursing Office when there was a need to access the Crisis Response Team.

Review of Patient #1's medical record revealed the facility admitted the patient on 04/25/14, with diagnoses which included Borderline Intelligence Quotient (IQ), Asthma and Impulse Control Disorder. Continued review revealed Patient #1 was admitted on a court ordered involuntary hold related to determining competency to stand trial. Record review revealed Patient #1 was admitted to the facility from jail after being arrested for assault. Review of Patient #1's Nurse Shift Assessments, revealed the patient's behaviors and mood consisted of being easily agitated, manipulative, sarcastic, prone to outbursts and loud at times.

Review of the facility's investigation, dated 05/11/14 revealed MHA #1's written statement. Review of MHA #1's written statement, dated 05/11/14, revealed at 7:30 AM that morning she had been assigned Patient #1's care. MHA #1 noted Patient #1 was on close observation (staff to remain within twelve feet and clear view of the patient at all times). MHA #1 documented Patient #1 had made verbal assaults against her on 05/10/14, and she was still "upset" from this on the morning of 05/11/14. Continued review of the statement revealed on 05/11/14, Patient #1 asked other staff to obtain requested items and not MHA #1 who was assigned to him/her. MHA #1 documented when she questioned Patient #1 as to why he/she was doing this, Patient #1 became verbally threatening to MHA #1, pointing his/her finger in her face which the MHA noted she used Crisis Prevention Interventions (CPI) blocking techniques for. MHA #1 noted when Patient #1 and herself were in the patient's room, she attempted to walk away from him/her, and Patient #1 would walk up to her and begin again. Review of the statement revealed MHA #1 was able to get to the room door and left the room to tell staff to get Patient #1. According to the written statement, another staff person tried to "calm" Patient #1, and the Charge Nurse came to the patient's room where Patient #1 made false allegations about MHA #1 pulling his/her hair. MHA #1 documented Patient #1 continued to threaten her, calling her into his/her room and Patient #1 stated, "Come on, hit me right here." Further review revealed MHA #1 told the patient, "I am not going to fight you, you are not worth my job." Review of the statement revealed Registered Nurse (RN) #1/Charge Nurse attempted to calm Patient #1 down and MHA #3 was going to take over the patient's care. MHA #1 noted MHA #3 left the incident area stating she needed to get something from the break room leaving MHA #1 standing there with Patient #1. MHA #1 stated while she continued standing there with her clipboard and coffee in her hands, Patient #1 continued to make allegations and verbal threats towards her. MHA #1 documented she stood there "boiling" at that point and noted she got "emotionally upset", squeezed her coffee cup, through the clipboard down and walked out.

An attempt to interview MHA #1 by phone was made on 05/22/14 at 8:01 PM; however, was unsuccessful.

Interview with Patient #1, on 05/21/14 at 2:42 PM, revealed on 05/11/14, MHA #1 was telling him/her to "shut the f... up" while they were in his/her room and no one saw it occur. Patient #1 stated MHA #1 slammed the bathroom door, trying to smash his/her fingers in the bathroom door and he/she asked MHA #1, "was that supposed to scare me?" Patient #1 indicated after this he/she and MHA #1 got into a physical altercation with him/her yelling for help; however, no staff responded. Patient #1 reported MHA #1 then walked out into the hallway, and two (2) staff members responded, MHA #5 and MHA #7. Patient #1 stated the situation between the patient and MHA #1 got "heated" again and they got into a verbal argument. According to Patient #1, MHA # 1, threw her clipboard at him/her and hit him/her in the leg, and then left his/her room throwing her cup of coffee on the hallway floor.

Interview with Patient #5, on 05/21/14 at 4:22 PM, revealed he/she was sitting in the game room during the time of the incident and reported hearing Patient #1 telling MHA #1 she was "afraid to fight" and was "calling" the MHA names. Patient #5 stated after this, he/she observed MHA #1 leaving the unit crying. Patient #5 revealed MHA #1 was very soft spoken and sweet and indicated this was not her usual behavior; however, added, "everybody" had "a breaking point."

Interview, on 05/21/14 at 3:00 PM, with MHA #5, revealed an incident on 05/10/14 lead to the situation which occurred on 05/11/14. MHA #5 reported on 05/10/14, Patient #1, Patient #2, and Patient #3, were standing around the nursing station, and MHA #1 asked the patients to disperse from the nurse's station as they were getting too loud. According to MHA #5, after this Patient #1 began to tell staff that MHA #1 was "singling" him/her out, and was not being fair to him/her. She stated when it was time for MHA #1 to be on close observation with Patient #1, the patient began "taunting" MHA #1, making statements indicating he/she was going to "do this and that" to her. Later on 05/10/14, MHA #5 revealed she saw MHA #1 talking to the nurses and reported she heard MHA #1 requesting to be placed with a different patient due to Patient #1 "threatening" her. MHA #5 stated she thought something was wrong because MHA #1 was often the "peacemaker" on the unit. Continued interview with MHA #5 revealed on 05/11/14, MHA #1 was again assigned to close observation of Patient #1, even though she had told the nurses on 05/10/14 that Patient #1 was "threatening" her. She reported around 9:00 AM, she heard "yelling" coming from the direction of Patient #1's room, and she was at the nurse's station and could not leave there. MHA #5 stated she did get RN #1/Charge Nurse and asked MHA #2 to go try to de-escalate the situation. She stated she did not witness the incident which occurred between MHA #1 and Patient #1 on 05/11/14. However, MHA #5 stated when MHA #1 reported to staff she was not comfortable working with Patient #1, she should not have been assigned to the patient's care and close observation. She reported the incident that occurred on 05/11/14 could have been avoided had the nurses not assigned MHA #1 to Patient #1's care.

Interview, on 05/21/14 at 3:39 PM and on 05/22/14 at 7:23 PM, with MHA #2 revealed MHA #1 appeared "stressed" and "aggravated" to her on 05/11/14. She stated she heard MHA #1 state "they are trying to set me up", when MHA #1 reviewed her assignment for the day. MHA #2 stated she talked to MHA #5 in regards to what occurred the day before, 05/10/14, and based on her discussion felt MHA #1 should not have been placed on close observation with Patient #1. She stated MHA #1 was "acting different" on 05/11/14, and was not as "upbeat" as she normally was. According to MHA #2, MHA #1 was always happy but did not "look well that day" when she saw her. Continued interview revealed she was informed of the verbal altercation between Patient #1 and MHA #1 and MHA #5 asked her to intervene. She stated by the time she got to Patient #1's room to intervene, it was too late as MHA #1 had already raised her voice at the patient. Further interview with MHA #2 revealed when the verbal altercation occurred between MHA #1 and Patient #1, RN #1/Charge Nurse should have "hollered" for someone to assist with the situation, however, RN #1/Charge Nurse did not call for anyone to intervene. She indicated staff had responded to the "yelling" between MHA #1 and Patient #1.

Interview, on 05/21/14 at 4:42 PM, with MHA #3 revealed she worked on 05/10/14 and 05/11/14. She reported Patient #1 was observed to be very accusatory and threatening towards MHA #1 on Saturday 05/10/14, and indicated MHA #1 had asked the nurses to be removed from close observation with the patient which they honored. However, she stated on 05/11/14, MHA #1 was again assigned to be on close observation with Patient #1. MHA #3 reported she thought based on what happened the day before, MHA #1 should not have been assigned to Patient #1 on 05/11/14. She stated on 05/11/14, Patient #1 was "taunting" MHA #1 and trying to get the MHA to "fight" him/her. Continued interview with MHA #3 revealed MHA #1 would walk away from Patient #1; however, the patient would follow her. MHA #3 stated she asked Patient #1 if she wanted her to take over his/her care; but, the patient continued to state she did not want to work with MHA #1. Further interview with MHA #3 revealed RN #1/Charge Nurse had worked on 05/10/14, and was aware of MHA #1's concerns with caring for Patient #1, prior to 05/11/14. She indicated MHA #1 should not have been assigned to care for Patient #1 on 05/11/14 and the incident could have been prevented if she had not been assigned to the patient.

Interview, on 05/21/14 at 5:34 PM and 05/22/14 at 6:45 PM, with Licensed Practical Nurse (LPN) #1, revealed Patient #1 was a "mass manipulator" and knew every "trick in the book". She stated on 05/10/14, she heard Patient #1 tell MHA #1 that he/she would "f... her up" and reported the patient had developed a dislike for MHA #1. LPN #1 revealed on 05/11/14, RN #1/Charge Nurse stated to her if she "put" MHA #1 on Patient # 1 for a few hours "maybe" the patient would "sleep in". LPN #1 stated MHA #1 was always "very kind hearted" and patient, and she had never seen the MHA be verbally or physically abusive in any way. She stated she did not see the incident which occurred on 05/11/14, but heard Patient #1 "going at it" with MHA #1. LPN #1 reported however, she knew it was not good when she saw MHA #1 leave the unit. LPN #1 reported the facility's process for de-escalating a patient would be to intervene and separate the patient and staff, and the staff member was to leave the unit and other staff would assist. Continued interview revealed work related stress or burnout could be defined as staff feeling as though they were going to lose control. She stated staff feeling this way would ask someone to relieve them, so they could calm down. LPN #1 reported staff should have asked for relief to avoid any type of situation like the one which occurred on 05/11/14. Further interview revealed she heard MHA #1 talk to nurses and other staff about being relieved from close observation with Patient #1, but did not recall MHA #1 addressing the concern with RN #1/Charge Nurse.

Interview, on 05/21/14 at 5:53 PM, with MHA #4 revealed the facility's process was if a verbal altercation between patients and/or patient and staff, staff were to intervene and try to de-escalate the situation. If the situation did not "calm down", then the nurse was to intervene, and if this did not help the doctor should be contacted for possible medication adjustment. MHA #4 stated she worked on 05/10/14 and had observed Patient #1 "smarting off" to MHA #1. She stated Patient #1 was making statements to MHA #1 indicating he/she was going to kick MHA #1's "ass". MHA #4 reported she heard MHA #1 stating she (MHA) could not deal with "that" right now and requested another patient assignment from the nurses. She reported MHA #1 was re-assigned to care for another patient and she took over care of Patient #1 on that day. MHA #4 stated on 05/11/14, MHA #1 told her, "I told them yesterday that I can't be with" Patient #1, after MHA #1 looked at her assignment for the day and noticed she was assigned Patient #1's care and close supervision again that day. She indicated the nurses should not have placed MHA #1 in that situation after what had occurred the day before. MHA #4 reported she did not observe the incident which occurred between MHA #1 and Patient #1 on 05/11/14; however, had heard "screaming" from where she was providing close observation of another patient. MHA #4 stated MHA #1 was always "nice" to everybody and it was not in her nature to act the way she did that day. She stated MHA #1 always "went out of her way" for the patients.

Interview, on 05/22/14 at 7:20 PM, with RN #1/Charge Nurse revealed she did not know MHA #1 "very well". She reported on 05/11/14, she was told by another staff member there was an altercation going on between MHA#1 and Patient #1. However, observation of the facility's video revealed MHA #1 observed walking with RN #1/Charge Nurse to Patient #1's room. Continued interview with RN #1/Charge Nurse revealed when she reached Patient #1's room, the patient was making accusations towards MHA #1 and stated she observed MHA #1 making "horrible" statements to Patient #1. She reported she thought about "putting" her hands on MHA #1, but was unsure of what would happen if she did that. She indicated she proceeded to de-escalate the situation; but, could not explain her process for this situation as de-escalating usually involved patients not staff. RN #1 reported the process for intervening in an altercation between staff and patients or patients to patients was to observe and ensure the safety of the unit and the patients. She revealed the process included staff trying to de-escalate the situation to "minimize" it. Further interview with RN #1/Charge Nurse revealed if the incident continued to be a situation staff could not control, staff should call security. RN #1/Charge Nurse stated she worked on 05/10/14, and was aware of the incident which occurred between Patient #1 and MHA #1 that day; however, did not believe what happened that day had anything to do with the incident which occurred on 05/11/14. She stated if a staff member was stressed, they should tell the nurse they needed a break and explain they might not be able to deal with that particular patient. In addition, she added the stressed staff member should also inform other staff about their stress or burnout. RN #1 reported MHA #1 did not talk to her about not feeling comfortable with caring for Patient #1 and did not appear to be stressed on 05/11/14.

Interview, on 05/22/14 at 5:34 PM, with RN #3 revealed he worked on 05/10/14, and MHA #1 cared for Patient #1 a "good portion" of his shift, which was from 7:00 AM to 12:00 PM. He stated Patient #1 could be difficult to care for and when he worked as Charge Nurse, he would try to only put staff with Patient #1 for about one (1) hour each. RN #3 reported he observed Patient #1 and Patient #2 at the nurse's station on 05/10/14 when MHA #1 asked them to move. He stated MHA #1 approached him and RN #5 later and stated she wished they had "backed" her up. RN #3 stated he told MHA #1 sometimes you have to "choose" your battles, adding that it was difficult to keep patients from hanging around the nurse's station. He stated MHA #1 was usually reserved, composed, and professional with patients and other staff, and believed he was not present when MHA #1 approached RN #5 requesting to be reassigned to another patient. RN #3 stated however he had noticed MHA #1 appeared to be stressed that day (05/10/14). He reported staff stress and/or burn-out was when an individual reached their "breaking point" and then an "unfortunate" event could occur. He reported that if the stress or burn-out were not recognized, it could endanger the staff or "patient". RN #3 indicated RN #1/Charge Nurse should have switched MHA #1's assignment on 05/11/14, to prevent the incident which occurred. He stated staffing was a big concern and had caused "a lot of stress" for staff.

Interview, on 05/21/14 at 5:22 PM, with RN #2/Charge Nurse revealed she did not work 05/11/14; however, was aware of the incident which occurred that day. She reported the behavior of Patient #1 was often confrontational and indicated MHA #1's behavior was a "little stressed". RN #2/Charge Nurse stated if a staff member was stressed, the facility's process was to ask the staff member to take a break. RN #2 reported the Charge Nurse's duties were to recognize if a patient's behavior was escalating, and step in to try to assist. She reported the Charge Nurse should then try to de-escalate the patient's behaviors and if that did not work, try something else. She stated the Charge Nurse should separate the patient and staff person which generally helped, and reported she would not expect the staff person to continue to care for the patient afterwards. She stated she would reassign the staff person to another patient which tended to "solve the problem".

Interview, on 05/22/14 at 7:39 PM, with Director of Risk Management revealed in regards to staff stress, staff had to be able to vent and release when working in an environment such as the facility's. She stated the facility's environment "always stressful" for staff and added patients were continuously verbally and physically abusive to staff. The Director of Risk Management stated if staff did not have a way to release or have someone to talk to, then they could reach their "breaking point", which was what occurred in the incident involving MHA #1 and Patient #1 on 05/11/14. She reported though Nurse Managers were on the unit and work close with the employees, there was no "magical method" to recognize stress and burn-out in the MHA's. Continued interview with the Director of Risk Management revealed staff should be referred to the "Crisis Response Team", if they appeared to be stressed; however indicated this had not occurred for MHA #1. She reported she had not been aware of the events which occurred on 05/10/14 between MHA #1 and Patient #1 prior to the survey visit date. However, she indicated she should have been aware of it. The Director of Risk Management stated MHA #1's employment had been terminated.

Interview, on 05/22/14 at 6:39 PM, with the Senior Nursing Administrator revealed to prevent harm to patients, staff should attempt to "defuse" the situation and "remove" the danger. He stated in the incident involving Patient #1 and MHA #1, the MHA should have been removed from the unit. He reported the "goal" was not to "lay hands" on anyone, but to keep everyone safe. Continued interview revealed his nursing staff should be able to assess for stress and burn-out among the MHA's, since they look for these symptoms in patients everyday. He reported staff should be looking at emotional changes occurring with the MHA. According to the Senior Nursing Administrator, the facility's CPI talked about keeping staff "healthy", and the nursing staff should evaluate the MHA's and ask them questions to determine if the MHA was "fit for duty". He reported if MHA #1 was stressed, she should have been evaluated and questioned about her concerns with caring for Patient #1 by the nurses. In addition, he stated then MHA #1 should have been reassigned or sent home if she was really that stressed out, to prevent possible endangerment of other patients. He reported he was not aware of the events which occurred on 05/10/14 between MHA #1 and Patient #1; however, stated he should have been notified.